Aims. This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. Methods. In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. Results. The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. Conclusion. The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745–751

Aims. The COVID-19 pandemic has triggered transformative change in how clinicians interact with their patients. There has been a shift away from face-to-face toward virtual consultations. However, the evidence to support this change in practice is unclear. The aim of this study was to systematically review the evidence base for virtual consultations for orthopaedics. Materials and Methods. Two independent reviewers performed a literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and Scopus databases. Only studies reporting outcomes following the use of telemedicine for diagnosis, consultation, rehabilitation, and follow-up were included. Outcomes analyzed were: 1) Patient and clinician satisfaction, 2) Clinical outcome measures, and 3) Cost analysis of traditional vs teleconsultation. Results. A total of 41 studies were included. Fifteen studies compared clinical outcomes of telemedicine against a matched traditional cohort. Of these 15 studies, two demonstrated non-inferiority, nine showed no statistically significant difference and four found telemedicine to be superior. Eleven studies recorded patient reported outcomes, which demonstrated high patient satisfaction. Nine studies reported decreased costs when telemedicine was compared to traditional care. The remaining 6 studies had varied aims and methodologies that didn't fit well with any of these sub-headings. Conclusion. While the available evidence is limited, the studies assessed in this systematic review show that telemedicine can deliver high quality healthcare with good clinical outcomes and high patient satisfaction in a cost effective manner. Further studies are required to validate telemedicine for specific trauma and orthopaedic diagnoses

Introduction. Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS). Materials & Methods. The telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires. Results. Baseline data collected from April 2019 to April 2021 showed that our median LOS for patients undergoing external fixation was 6 days with 36% of patients being discharged at day 4 or earlier. After implementation of telemedicine, median LOS reduced to 4 days with 50% of patients leaving hospital in 4 days or less. Service user responses demonstrated that 100% felt that sufficient information was provided by the CNS team, a mean score of 8.4/10 was reported when asked how confident they were when adjusting the fixator. When asked how the service could be improved access to a recorded video was suggested. Conclusions. Initial fixator adjustment support via telemedicine is not appropriate for all of our patient group due to a lack of access or co-morbidities/ social issues that necessitate a prolonged hospital stay. However, this project has demonstrated that it has had positive long-term benefits within our service through reducing our median length of stay by 2 days without compromising patient satisfaction with their care

A significant proportion of patient transfers in Ontario are from long-term care facilities for consultation of musculoskeletal (MSK) issues. These transfers are costly for patients and the healthcare system. This study evaluated the utility of a Telemedicine MSK (TeleMSK) service for long-term care patients requiring an orthopaedic consultation. A cross-sectional study was used to assess TeleMSK from September 2018 to April 2019. 26 long-term care facilities participated in this study, which included 32 long-term care patients assessed via TeleMSK and 27 telemedicine liaisons. Telemedicine Satisfaction Scale (TeSS) and the Telemedicine Usability Questionnaire (TUQ) surveys were used to evaluate the usefulness of the TeleMSK program. Patients and families rated voice (64.3%) and visual (71.4%) quality of TeleMSK to be excellent as well as the length of consultation (92.9%). 78.6% participants rated explanations from physicians to be excellent, 92.9% of the participants rated the carefulness, skillfulness, respect, and sensitivity of the attending physician to be excellent (85.7%). Patients felt privacy and confidentiality was maintained and respected throughout the consultation. The majority of telemedicine liaisons agreed that TeleMSK improved accessibility and productivity of consultations and 81.5% of the telemedicine liaisons strongly agreed that they would use TeleMSK again in the future. TeleMSK allowed for accessible, timely orthopaedic consultations without compromising the quality of patient care. Patients, families, and telemedicine liaisons rated their experience and use of TeleMSK as excellent. Barriers to healthcare are important issues to be addressed in the long term care population. This can be conducted efficiently and effectively with Telemedicine

Aims. In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. Methods. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”. Results. A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training. Conclusion. Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640

PROBLEM. Since the COVID-19 pandemic of 2020, there has been a marked rise in the use of telemedicine to evaluate patients following total knee arthroplasty (TKA). Telemedicine is helpful to maintain patient contact, but it cannot provide objective functional TKA data. External monitoring devices can be used, but in the past have had mixed results due to patient compliance and data continuity, particularly for monitoring over numerous years. This novel stem is a translational product with an embedded sensor that can remotely monitor patient activity following TKA. SOLUTION. The Canturio™ TE∗ System (Canary Medical) functions structurally as a tibial extension for the Persona® cemented tibial plate (Zimmer Biomet). The stem is instrumented with internal motion sensors (3-D accelerometer and gyroscope) and telemetry that collects and transmits kinematic data. Raw data is converted by analytics into clinically relevant gait metrics using a proprietary algorithm. The Canturio™ TE∗ will monitor the patient's gait daily for the first year and then with lower frequency thereafter to conserve battery power enabling the potential for 20 years of longitudinal data collection and analysis. A base station in the OR activates the device and links the stem and data to the patient. A base station in the patient's home collects and uploads data to the Cloud Based Canary Data Management Platform (Canary Medical). The Canary Cloud is structured as an FDA regulated and HIPPA-compliant database with cybersecurity protocols integrated into the architecture. A third base station is an accessory used in the health care professional's office to perform an on-demand gait analysis of a patient. A dashboard allows the health care professional and patient to monitor objective data of the patient's activity and progress post treatment. MARKET. The early target market for this device includes total joint surgeons who are early adopters of technology and currently utilize technology in their practice. The kinematic data provided by the Canturio™ TE∗ System will enable clinicians to augment patient care by reviewing their objective gait metrics. In the future, this data has the potential to be integrated with other Zimmer Biomet technologies, such as the Rosa™ Knee robotic platform, mymobility™, and sensored devices like iAssist™, to provide the surgeon with a complete pre-surgical functional assessment, intraoperative data, and post-operative functional data. PRODUCT. Persona IQ will be the combination of the proven Persona personalized total knee system with the Canary Medical Canturio™ TE∗. TIMING AND FUNDING. The Canturio™ TE is currently under De Novo FDA review for market clearance; it is not yet available for commercial distribution. The plan is to launch the product in 2021 pending regulatory De Novo grant. This effort is a partnership between Zimmer Biomet and Canary Medical. ∗ The Canturio™ - TE is currently under De Novo FDA review for market clearance; it is not yet available for commercial distribution

Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future. Cite this article: Bone Jt Open 2021;2(5):301–304

Introduction. Surface sensor technology provides useful information about the status of an individual's health and been available for many years, but has not been widely adopted by orthopaedic surgeons. However, its usage may be become more prominent as COVID-19 has created a shift towards telemedicine. This study reports the use of a joint specific surface sensor to remotely monitor the recovery of patients who underwent knee replacement surgery prior to the enforced stay-at-home social distancing necessitated by the COVID-19 pandemic. Methods. The study group consisted of 29 patients who underwent primary, unilateral total knee arthroplasty (TKA). A knee joint specific surface sensor (TracPatch™) was placed following surgery and kept on patients for 3 weeks postoperatively. The patients’ range of motion (ROM), exercise compliance, distance walked, pain, skin temperature, and incision appearance were monitored and transmitted electronically to health care providers. Patients were grouped by gender, age and BMI for analysis of functional outcome measurements. Results. Patients tolerated wearing the device without complications. Additionally, both patients and physicians were able to monitor patient data in real time via a mobile phone or web application. The mean maximum flexion and minimum extension did not significantly change from postoperative week 1 to postoperative week 2 and week 3. However, the mean number of steps taken increased from 4,923 steps in postoperative week 1 to 8,163 steps week 2 (p=0.01) and 11,615 steps week 3 (p<0.001) postoperatively. There were no statistically significant differences in ROM or number of steps between the different gender, age, and BMI groups. Conclusion. The use of a joint specific surface sensor that provides novel pre- and postsurgical information is a valuable addition to surgeons’ remote care capability. These devices promise to accelerate the adoption of telehealth by orthopedic surgeons

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve.

Cite this article: Bone Joint Open 2020;1-6:272–280.

Aims

COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic.

Aims

The purpose of our study was to determine which groups of orthopaedic providers favour virtual care, and analyze overall orthopaedic provider perceptions of virtual care. We hypothesize that providers with less clinical experience will favour virtual care, and that orthopaedic providers overall will show increased preference for virtual care during the COVID-19 pandemic and decreased preference during non-pandemic circumstances.

Aims

The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era.

Aims

The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work.