James Derek Wylie

Background: Venous thromboembolism (VTE) includes pulmonary embolism (PE), and deep vein thrombosis (DVT) and is a complication of total hip and knee (THR/TKR) joint replacement surgery. Guidelines historically recommended anticoagulation thromboprophylaxis for patients undergoing elective THR/TKR, and aspirin has emerged as an alternative for select patients. VTE risk stratification may identify patients who can safely receive aspirin. Limited evidence informs how to risk-stratify THR/TKR patients, then recommend risk-stratified thromboprophylaxis. Methods: We derived and implemented “Standardized Thromboembolism Prophylaxis in Orthopedic Patients to prevent Venous ThromboEmbolism (STOP-VTE),” an evidence-based electronic heath record embedded VTE risk assessment model in our 23-hospital–integrated health system. The model classified patients as at high or standard risk of VTE and recommended anticoagulation (mostly apixaban 2.5 mg twice daily for 28 days) or aspirin (81 mg twice daily) prophylaxis, respectively. The primary implementation outcome for this prospective management study was adherence to STOP-VTE guidance, and the primary clinical outcome was VTE. Among 38,207 consecutive patients, we recorded surgeon adherence to STOP-VTE guidance and outcome rates of 90-day VTE, PE, DVT, mortality, and rates of 30-day major bleeding, emergency department visits, and hospitalization. Outcomes were recorded for 2 years preceding implementation of STOP-VTE (baseline) and for 6.8 years after STOP-VTE implementation (intervention). Results: For the primary implementation outcome during the baseline period, 57.4% (1,467/2,554) received aspirin or anticoagulant prophylaxis consistent with risk classification, and during the intervention, this rate increased to 77.8% (27,744/35,653; p < 0.001). Clinical outcome rates at baseline vs. intervention were the following: for 90-day VTE, 0.9% vs. 0.65%; PE, 0.7% vs. 0.39%; DVT, 0.31% vs. 0.29%; and mortality, 0.16% vs. 016%. Thirty-day major bleeding was 0% vs. 0.04%; emergency department and rehospitalization rates were 6.97% vs. 5.31% and 2.45% vs. 1.71%, respectively. Pulmonary embolism, emergency department, and hospitalization visit rates significantly declined. Conclusion: STOP-VTE guidance was implemented and broadly adopted. Adherent chemoprophylaxis was associated with low rates of 90-day VTE, major bleeding, decrease in anticoagulant chemoprophylaxis, increase in aspirin chemoprophylaxis, and cost savings. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

This article describes how we were able to decrease patient radiation exposure from hip computed tomography (CT) for hip preservation evaluation without a degradation of image quality. This is a retrospective review of a quality improvement project. The study included patients who underwent hip CT at a single center as part of a clinical evaluation for young adult hip pain. Four distinct protocols were used during the study period. All protocols included at CT scan of the hip with slices through the distal femur to evaluate femoral version. Patient variables collected included age, gender, and body mass index (BMI). The dose–length product was collected and the effective dose in millisieverts (mSv) was calculated. Differences in dose between protocols were compared using analysis of variance with appropriate post hoc tests and multivariate general linear regression. A total of 613 patients underwent hip CT during the study period with 304 patients in protocol 1, 83 in protocol 2, 136 in protocol 3, and 91 in protocol 4. When controlling for age, gender, and BMI there was a significant decrease in effective dose of radiation from protocol 1 (3.63 mSv) to protocol 2 (3.06 mSv) (p = 0.002) and protocol 2 (3.06 mSv) to protocol 3 (2.16 mSv) (p < 0.001). There was no difference between protocol 3 (2.16 mSv) and protocol 4 (2.10 mSv) (p = 0.269) but protocol 4 was easier to administer. In regression modeling, BMI (p < 0.001) and protocol used (p < 0.001) were independent predictors of effective radiation dose (model R ²= 0.585). Through a longitudinal clinical quality improvement project, we were able to decrease the effective radiation exposure to patients undergoing hip CT for hip preservation evaluation by close to 50%. Only CT protocol used and patient's BMI were predictors of ionizing radiation exposure. Level of Evidence Level 3, retrospective comparative study. The project was approved by the Intermountain Healthcare Institutional Review Board as a clinical quality improvement project. Received: 29 September 2022 Accepted: 04 April 2023 Article published online: 24 July 2023 © 2023. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Purpose: To determine the relationship of increased femoral anteversion and borderline acetabular dysplasia on the outcomes of hip arthroscopy for femoroacetabular impingement in a female cohort of patients. Methods: This is a retrospective study of female patients undergoing hip arthroscopy for femoroacetabular impingement. All patients had preoperative radiographs and computed tomography scans from which lateral center edge angle (LCEA) and femoral anteversion were measured. Patient outcome was quantified by preoperative and postoperative International Hip Outcome Tool 12‐item instrument (iHOT‐12). All patients had follow‐up at 2 to 4 years postoperatively. Published values for minimum clinically important difference, substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and a normal or abnormal hip were used to determine outcome as well as the final score and delta of the iHOT‐12. Results: There were 243 female patients included in the cohort (83% follow‐up) who had iHOT‐12 scores at 2‐ to 4‐year follow‐up (mean 36.9 months). Female patients with combined LCEA ≤25° and femoral anteversion >20° had lower final IHOT‐12 scores ( P = .001) and delta iHOT‐12 ( P = .010) and were less likely to achieve a normal hip ( P = .013), minimum clinically important difference ( P = .018), SCB ( P < .001), or PASS ( P < .001) and more likely to have an abnormal hip ( P = .002). In addition, patients with an LCEA ≤25° and normal femoral version were less likely to achieve a normal hip ( P = .013), SCB ( P < .001), and PASS ( P < .001) compared with those with normal acetabular coverage (all P < .05). There was no difference in these outcome measures between the groups with an LCEA >25° with or without increased femoral version. Conclusions: Female patients with femoral anteversion >20° and borderline acetabular dysplasia did poorly after hip arthroscopy. However, those with increased femoral anteversion and normal acetabular coverage had outcomes similar to control hips. Level of Evidence: Level IV, case series.

The management of the hip capsule has been a recent area of controversy in hip arthroscopy. Over the past 5 years, there has been mounting biomechanical and clinical evidence that complete capsular closure is an important step to achieve the best and most durable outcome from hip arthroscopy. Numerous studies in the laboratory have shown that repairing the capsulotomy during simulated hip arthroscopy establishes normal hip biomechanics. Multiple studies have also reported improved clinical outcomes and less conversion to total hip arthroplasty in patients undergoing capsular repair. We have published that patients improve after revision hip arthroscopy for repair of capsular defects. I think it is safe to say that complete capsular closure after hip arthroscopy is becoming the standard of care in our field.

Telehealth use has increased significantly of late. However, outside of total hip and knee arthroplasty, there is minimal evidence regarding its efficacy in orthopaedics and postoperative rehabilitation. To determine the efficacy and cost-effectiveness of a transition to postoperative telehealth physical therapy in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI). Cohort study; Level of evidence, 3. Included were 51 patients undergoing postoperative physical therapy after hip arthroscopy for FAI. The intervention group consisted of patients undergoing initial in-person visits followed by a transition to telehealth physical therapy for 3 months postoperatively (group 1; n = 17). Comparison groups included patients undergoing in-person physical therapy with the same physical therapy team as the telehealth group (group 2; n = 17) and patients undergoing in-person therapy with a different therapy team at the same facility (group 3; n = 17). All groups were matched 1-to-1 by patient age and sex. All patients completed the short version of the International Hip Outcome Tool (iHOT-12) both preoperatively and at 3 months postoperatively. At 3 months postoperatively, it was determined whether patients met the minimally clinically important difference (MCID; ≥13 points) or substantial clinical benefit (SCB; ≥28 points) or whether they reached a Patient Acceptable Symptomatic State (PASS; ≥64 points). Billed charges were recorded as a measure of cost. The overall mean age of the study patients ranged from 33 to 34 years. Among the 3 groups, there was no significant difference in the preoperative, postoperative, or pre- to postoperative change in iHOT-12 scores or in the percentage of patients meeting MCID, SCB, or PASS at 3 months. Group 1 had significantly lower mean costs ($1015.67) compared with group 2 ($1555.62; P = .011) or group 3 ($1896.38; P < .001). In this pilot study, telehealth physical therapy after hip arthroscopy was found to lead to similar short-term outcomes and was cost-effective compared with in-person physical therapy.

To review slipped capital femoral epiphysis (SCFE), with a focus on new insights into its etiology and evolving methods of operative fixation.

Modular Multi-level Converters (MMC) for medium voltage applications need to be compact and low-loss but also must have good waveform quality. This makes the choice of Sub-Module (SM) voltage rating and quantity a challenging compromise. An extra degree of design freedom is possible if modules in each arm are a mixture of nominal voltage ratings. A design is investigated here with several high voltage SMs for bulk power processing and two low voltage SMs for waveform following control. Power loss, efficiency and total harmonic distortion are compared against two designs of conventional MMC of equivalent power rating and waveform distortion level, but different SM voltage choices. A new low-level controller for SM rotation is devised which deploys different SM types for the different purposes, but also ensures charge balancing. Simulation results show reduced power loss for an MMC with mixed voltage-rated SMs within the same arm, when compared against the conventional MMCs.