Early Postoperative Mobilization Research Articles

Basic principles of anesthesia and postoperative analgesia in patients operated within an enhanced recovery after surgery (ERAS) protocol

The Enhanced Recovery After Surgery (ERAS) system is a collection of preoperative, intraoperative, and early postoperative measures. The primary goal of gynecological surgery is a rapid and uneventful recovery from oncological and standard procedures, particularly in patients over the age of 65. The goal is to achieve comparable results to those obtained with minimally invasive procedures. Certain features of the ERAS system are similar to those of standard surgical procedures. These are the measures taken to prevent thromboembolism and to promote early postoperative mobility. Anesthesia and postoperative analgesia are critical components of achieving the ERAS system's objectives. The ERAS protocol requires multimodal non-opioid postoperative analgesia, infiltration of the surgical wound with a local anesthetic, and avoidance of opioid analgesics. We discuss current data on patient management according to the ERAS protocol for anesthesia and analgesia in order to minimize the body's stress reactions, promote early mobility, and reduce postoperative complications. ERAS protocol has gained popularity in recent years in a number of centers, primarily in the United States and Europe, due to its direct impact on hospital stay length, healthcare costs, and benefits for patients, their relatives, and caregivers. Keywords: ERAS protocol; multimodal opioid-sparing analgesia; local infiltration anesthesia.

69 Early Post-operative Mobilization After Treatment of Burn Wounds with Autologous Skin Cell Suspension

IntroductionEarly mobilization has become popular in the literature and the benefits in critically ill patients are well-documented. However, early mobilization in burn care is undefined. Clinical practice guidelines regarding post-operative mobilization (POM) of patients with burn injury, especially after autografting, are limited, resulting in significant practice variance among burn centers. Furthermore, data on mobilization after treatment with autologous skin cell suspension (ASCS), is even more limited, and wider practice variation exists. We hypothesize early POM is safe and does not compromise healing or lead to graft loss.MethodsA retrospective chart review was performed to examine mobility interventions utilized for patients, with mixed partial and full thickness burns, who received ASCS with polylactic acid sheet, with or without meshed splint-thickness skin grafting (STSG), over 6 months. Data included demographics, operative procedure, dressing, post-operative restrictions, POM date by burn therapy, and presence of graft loss ( >25% of grafted area with need for regrafting). The data was analyzed to corelate POM day and graft success. Initially, the authors utilized manufacturer splinting guidelines before becoming more judicious with aggressive early mobilization. Patients at risk of noncompliance and graft sheer were splinted.ResultsFifteen patients were included in the study. In those patients, 25 body areas were grafted with 17 areas receiving ASCS with polylactic acid sheet and 8 areas additionally receiving STSG. On post-operative day (POD) 0, four areas were splinted and no range of motion (ROM) was performed at the joint. The authors splinted 3 out of 4 patients (75%) due to initial manufacturer splinting guidelines. The 4th patient was splinted due to compliance concerns. For the other 21 areas, active ROM, functional mobility and performance of activities of daily living with functional movement was allowed on POD 0. A burn therapist actively treated 64% of patients on POD 0-1 and 100% of patients were treated by POD 2. Minimal patchy graft loss (median 1.5%) was noted in 6 grafted areas including 1 area which crossed a knee despite immobilization. No graft loss was related to POM and was attributed to factors including infection or wound conversion and, by definition, no significant graft loss was found.ConclusionsWhile the sample size is limited, this study suggests early POM of ASCS is safe and does not lead to graft loss. Considerations for mobilization techniques, such as ROM and functional mobility, should include joint involvement, presence of STSG with ASCS overspray, and other patient factors such as health literacy and compliance. Additional prospective studies should be dedicated to the examination of POM to develop clinical practice guidelines which can be widely utilized across burn therapy.

Double-Row Suture Anchor Fixation and Achilles Allograft Augmentation for Chronic Patellar Tendon Rupture Repair

Patellar tendon ruptures are functionally devastating injuries that result in failure of the knee extensor mechanism and can lead to a loss of ambulation. Chronic patellar tendon injuries are defined as tears greater than 2 weeks old and are typically more complex to manage than acute tears. Recently, the use of double-row suture anchor configurations has been explored as a technique to provide improved strength in addition to tendon-to-bone compression at the anatomic footprint. The purpose of this article is to describe a surgical technique involving chronic patellar tendon rupture repair using a double-row suture construct augmented with Achilles allograft. Our technique offers a variety of benefits and permits early postoperative mobilization.

Treatment of comminuted fractures of the bones of the lower leg with rod and pincer apparatus

From 1997 to 1999 thirty eight patients with splintered and polyfocal crus fractures (9 patients had open fractures) were treated by transosseous osteosynthesis using rod or pin-rod devices. Splintered diaphyseal fractures were of В and C groups according to AO/ASIF classification but peri- and intraarticular fractures were of A2,3 and C groups. In fractures with large intermediate fragments an universal reposition device with floating fixators of rods was applied. In cases of peri- and intraarticular fractures as well as in fractures with small intermediate fragments Gorodnichenkos pin-rod device was used. The device provided stable fixation and patients with diaphyseal crus fractures were allowed full weight bearing from 3-5 postoperative day. The operative intervention is a low traumatic one that promotes early postoperative mobilization of patients, decreases the term of hospital treatment (mean 8.9 days). Fracture healing was achieved in all patients, no complications such as the imfiammation of soft tissues surrounding pins or rods were observed. The fixation was 12-18 weeks.

Emergency Laparotomy.

Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.

The Effect of Postoperative Early Mobilization on the Healing Process and Quality of Life Following Radical Cystectomy and Ileal Conduit: A Randomized Prospective Controlled Trial

The Effect of Postoperative Early Mobilization on the Healing Process and Quality of Life Following Radical Cystectomy and Ileal Conduit: A Randomized Prospective Controlled Trial

Tranexamic acid improves early postoperative mobilization in cancer patients undergoing endoprosthetic reconstruction

Tranexamic acid (TXA) has been shown to decrease perioperative blood loss, transfusions, and cost in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. This study explored the effect of TXA administration on postoperative mobilization in these patients. This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic reconstruction; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. Postoperative physical therapy (PT)and occupational therapy notes were reviewed; patient ambulation distance and duration of therapies were recorded. Patients in the TXA cohort ambulated further on all postoperative days, which was significant on postoperative Day 1 (POD1)(p = 0.002) and postoperative Day 2 (POD2)(p < 0.001). The TXA cohort ambulated 85% further per PT session87.7versus 47.4 ft (p < 0.001) and participated 14% longer, 36.1versus 31.7 min (p < 0.001). Multivariate analysis identified a significant inverse association between postoperative hospitalization length and POD1, POD2, postoperative Day 3, and total ambulation (p < 0.001). Blood transfusion was independently associated with a 1.5 day increase in postoperative hospitalization (95% confidence interval:0.64-2.5; p < 0.001). TXA administration was associated with increased postoperative ambulation and endurance. Increased postoperative ambulation was associated with decreased length of stay and increased likelihood to discharge home.

Cementless Extensive Porous-Coated Mono-block Long Stem Hemiarthroplasty versus Proximal femoral Nail for Unstable Osteoporotic Intertrochanteric Fracture in the Elderly Patients: a retrospective study

Introduction: The treatment for unstable intertrochanteric fractures in the elderly patient has always been controversial. The aim of this study was to compare the outcome of porous coated cementless mono-block long stem hemiarthroplasty (CPH) and proximal femoral nail (PFN) on unstable intertrochanteric femoral fracture in the elderly patients. Methods: From March 2017 and March 2020, 132 elderly patients with unstable femoral intertrochanteric fractures were treated by CPH or PFN. 73 patients were treated using proximal femoral nail (PFN) and 59 were treated using hemiarthroplasty (CPH). Bleeding amount, weight training time, hospitalization time, Harris scores, one-year mortality, pre-existing disease and postoperative complications were analyzed. Results: The average follow-up time was 23.2 months in the CPH group and 22.9 months in the PFN group. No significant differences was found between the two groups in terms of demographic data. There was no significant differences between the two groups regarding the ASA score, pre-existing disease, postoperative complications, and revision surgery. The mean operation time and the average amount of blood loss were significantly higher in the CPH group (p&lt;0.05). Conclusion: Both PFN and CPH are two satisfactory methods for treating the elderly with unstable IT fractures but in the CPH group, early postoperative mobilization and decreased dependency are the primary advantages.

Early Postoperative Extubation is Associated with Shorter Hospitalization and Improved Short-Term Survival in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant operative time, hospital resources, and morbidity. We examine factors associated with hospital length of stay (LOS) and early overall survival (OS) after CRS/HIPEC. Patients who underwent CRS/HIPEC were evaluated for factors associated with LOS. Institutional learning curve influence was addressed by comparing early vs late cohorts. Variables with P < .200 after univariate analysis were considered for inclusion in multivariate linear regression modeling. Independent factors associated with OS were evaluated using the Kaplan-Meier method. Seventy patients underwent CRS/HIPEC (mean age 52.3years, 64.3% female, and 68.6% Caucasian). Presence of any surgical complication was found in 26 (37.1%), 28 (40%) remained intubated postoperatively, and the mean Peritoneal Carcinomatosis Index (PCI) score was 14.4 (10.4). Mean intensive care unit and hospital LOS were 2.9days (2.3) and 9.6days (3.6), respectively. After adjusting for covariates, only shorter time to postoperative ambulation (regression coefficient .92, P = .001) and early extubation (regression coefficient -1.90, P = .018) were associated with decreased hospital LOS on multivariate analysis. Immediate postoperative extubation conferred an independent early survival benefit on Kaplan-Meier analysis (mean OS 714.8 vs 473.4days, P = .010). There was no difference in hospital LOS or OS between early and late cohorts. Early postoperative extubation and shorter time to ambulation are associated with decreased hospital LOS. Moreover, CRS/HIPEC patients extubated immediately postoperatively have an early survival benefit. Every effort should be made to achieve early postoperative extubation and mobilization in CRS/HIPEC patients.

Perioperative care for major elective surgery: a survey of Brazilian physiotherapists

Abstract Introduction: Major surgeries are highly complex procedures and have a higher incidence of respiratory morbidity and mortality compared to other types of surgery. Postoperative pulmonary complications (PPC) are common after such surgeries and are associated with increased hospital stay, health care costs and surgical patient mortality. Objective: To investigate the most commonly used physical therapy techniques for the prevention and treatment of PPC among thoracic and abdominal surgery patients in all regions of Brazil. Methods: A total of 489 randomly selected physiotherapists who provided perioperative care for patients undergoing elective abdominal, thoracic or cardiac surgeries participated in this study. A questionnaire with nine questions about routine care and therapeutic choices for the surgical population was developed and assessed by 10 specialists before being administered to the physiotherapists. Results: Among the physiotherapists (63% with at least 5 years of experience with surgical patients), 50.9% considered the patient’s surgical risk in their treatment either always or often. A total of 53.8% patients were treated by the physiotherapist following a physician’s prescription. The most mentioned physical therapy techniques used to prevent PPC were postoperative mobilization/exercises (59.3%), postoperative lung expansion (52.8%), and preoperative advice (50.7%). In addition, 80.6% of the physiotherapists believe that incentive spirometry prevents PPC, while 72.8% expected this effect from positive airway pressure devices. Conclusion: Most physiotherapists in Brazil who work with surgical patients offer preoperative professional advice, use postoperative early mobilization and lung expansion techniques to prevent PPC, and consider the patient's surgical risk during treatment. In addition, some physical therapy sessions are routinely performed preoperatively.

Validity, Responsiveness, and Predictive Ability of the Japanese Version of the Cumulated Ambulation Score in Patients with Hip Fracture.

ABSTRACTObjectives:The aim of the current study was to investigate the validity, the responsiveness, and the predictive ability for discharge to own home of the Japanese version of the Cumulated Ambulation Score (CAS-JP). This was achieved by analyzing the CAS-JP after hip fracture surgery at multiple time points until patient discharge.Methods:Patients who underwent hip fracture surgery were evaluated using CAS-JP, the Barthel Index, and walking ability on postoperative day (POD) 1, 7, and 14 and at discharge. Floor and ceiling effects, responsiveness, and correlations between CAS-JP and other functional outcomes were assessed at each time point. The predictive ability of CAS-JP for discharge to own home was also analyzed using the area under the curve (AUC) of the receiver operating characteristic.Results:A total of 121 patients were included in this study. On POD7, POD14, and at discharge, strong correlations were observed between CAS-JP and the Barthel Index (r=0.81, 0.82, and 0.87, respectively), and between CAS-JP and walking status (r=0.82, 0.81, and 0.76, respectively). CAS-JP had a large effect size (1.64–2.25) and standardized response mean (1.49–1.81). The predictive ability of CAS-JP for discharge to own home, as indicated by the AUCs, were 0.73 (95% CI: 0.62–0.83) on POD7 and 0.74 (95% CI: 0.62–0.86) on POD14.Conclusions:CAS-JP has sufficient validity and responsiveness as a mobility assessment tool in postoperative hip fracture patients. Furthermore, this study showed that early postoperative mobility status evaluation using CAS-JP can sufficiently predict discharge to own home.

A Prospective Study on the Functional and Radiological Outcomes of AO Type C Distal Humerus Fractures in Adults Treated Surgically with Bicolumnar Fixation

Purpose: To study the functional and radiological outcomes of AO type C distal humerus fractures (DHFs) in adults treated surgically with bicolumnar fixation.&#x0D; Methods: A prospective study of 30 adult patients with AO/OTA type C fractures of the distal humerus treated operatively with bicolumnar fixation between September 2018 to December 2020 at Sree Balaji Medical College &amp; Hospital, Chennai was performed. Closed distal humerus fractures with intra-articular extension were fixed with bicolumnar plating, with orthogonal or parallel configuration of plate fixation decided intra-operatively. This was achieved in all patients after performing an olecranon osteotomy for better exposure of the fracture site, which was later fixed with either CC screws or K-wires with tension band wiring. The functional and radiological outcomes in this study group were assessed on regular post-operative follow-up. The Mayo Elbow Performance Score (MEPS) was used to evaluate the functional outcomes in our patients.&#x0D; Results: The mean age of the patients was 44 years, with 18 (60%) males and 12 (40%) females in the study. The right-sided elbow was more frequently involved (57%) in our study. The most common mode of injury was Motor Vehicle Accident (MVA) (14 cases; 47%), while domestic fall contributed to 10 (33%) cases. Fall from height and direct trauma to the elbow made up the rest of the cases, with a 10% incidence each. A majority of cases (22 cases; 73%) showed radiological union between 12-16 weeks post-operatively, whereas 8 cases (27%) united between 17-21 weeks. The Mayo Elbow Performance Score (MEPS) used to assess the functional outcome showed excellent results in 25 (83%) cases, good and fair results in 2 (7%) cases each, and a poor outcome in 1 (3%) case.&#x0D; Conclusion: For satisfactory results in intraarticular fractures of the distal humerus treated with bicolumnar plating, thorough pre-operative planning, posterior surgical approach with adequate exposure via olecranon osteotomy, anatomical inter-fragmentary stabilization by dual plating, and early post-operative mobilization with physiotherapy are important steps to be followed.

The Role of Minimally Invasive Percutaneous Pedicle Screw Fixation for the Management of Spinal Metastatic Disease

Optimal surgical management of spinal metastatic disease remains controversial. Skip and diffuse spinal lesions, patient frailty, and the need for timely adjuvant chemoradiation complicate surgical decision-making. Minimally invasive percutaneous pedicle screw fixation (MIPSF) is an attractive concept that can confer stability and allow early postoperative mobilization. To date, outcomes of the MIPSF technique remain under-investigated. A single-center retrospective review of patients undergoing percutaneous instrumentation for multilevel spinal metastatic disease between January 2012 and October 2020 was performed. Twenty-four patients were identified, and their primary tumor diagnoses, modified Tokuhashi scores, Spine Instability Neoplastic Scores, neurologic functions, pain scores, and procedure types were noted. Of these patients, 17 underwent fixation of 6 or more levels (L-MIPSF), whereas 7 underwent fixation of <6 levels (S-MIPSF). All patients had screw-and-rod constructs placed percutaneously using bi-planar fluoroscopy guidance. Patients undergoing corpectomy, multilevel laminectomies, or open posterior instrumentation were excluded. Improvement in pain and neurological function was noted in nearly all patients who underwent MIPSF. Average skin incision-to-closing time was 130 minutes, and standard deviation of 55 minutes. Likewise, the average estimated operative blood loss was 402 mL, and standard deviation of 388 mL. Only one patient required hardware revision due to proximal loss of fixation. Two patients required mini-open decompression procedures due to tumor recurrence at different levels than the index pathology. Multilevel minimally invasive spinal fixation is feasible in patients with diffuse spinal metastasis. The percutaneous nature of the technique minimizes dissection, blood loss, and operative times. Early outcomes of MIPSF are promising and demonstrate utility in avoiding multiple subsequent procedures in a cohort of deconditioned patients.

Malnutrition, poor function and comorbidities predict mortality up to one year after hip fracture: a cohort study of 2800 patients.

Despite extensive research, a complete understanding of factors influencing mortality risk after hip fractures is lacking.Previous research has focused on static risk factors; however, to improve outcomes, attention should be directed towards risk factors that may be optimised. The present study aimed to investigate the association of 19 risk factors with mortality among patients with hip fracture treated according to a well-defined guideline. The study was a retrospective analysis of a large prospective patient cohort with all consecutive patients surgically treated for a hip fracture from January 2011 to December 2017 included (n = 2800). Variables were obtained from patient records and the Holstebro Hip Fracture Database comprising prospectively registered data on demographics, comorbidity, malnutrition (low Body Mass Index (BMI) or albumin) and hospital stay (including fracture and surgical data, biochemistry, mobilisation and discharge). Outcomes were 30-day and one-year mortality. Patients were predominantly female (66%); median age 81.6years. Overall mortality was 9% at 30days and 24% at one year. Age ≥ 75years, male gender, nursing home residence, cognitive impairment, American Society of Anesthesiologists (ASA) score ≥ 3, BMI < 20kg/m2, albumin < 35g/l, creatinine ≥ 100µmol/l, a low New Mobility Score and no mobilisation were all associated with increased mortality at 30days and one year. In addition to non-modifiable risk factors, comorbidities (expressed as high ASA score and creatinine), malnutrition, and failure to achieve early post-operative mobilisation were associated with increased short and long-term mortality among patients with hip fracture: these are potentially modifiable. The effect of optimisation interventions warrants further research.

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.

Developing Assistive Bedside Furniture for Early Postoperative Mobilization in a Healthcare Setting With an Attentive Empathetic Design Approach.

This work endeavored to design and develop a tool to assist surgical patients with postoperative mobilization in a hospital. Early postoperative mobilization after surgery can effectively help prevent complications, but it is difficult to achieve in practice. An attentive empathetic design approach was used to gain insights into the users' functional needs, characteristics, contexts, as well as their emotional needs, behaviors, and psychology. The insights led to a design that leveraged psychological heuristics and habit-building principles to effect necessary mindset and behavioral changes of the stakeholders. Over four iterations, design ideas were prototyped, tested, and improved with participation of 30 patients and 30 nurses. Valuable insights were discovered. Most importantly, besides the medically critical need to avoid postoperative complications, the patients also had emotional needs for independence, confidence, and self-worthiness, while the nurses needed the patients' trust. Consequently, assistive bedside furniture prototypes were designed to enable the patients to move around safely by themselves. Feedback on the prototypes showed that the patients sat up more often, enjoyed doing more activities, became more confident and less fearful of moving around, and felt less burdening on the care providers. Moreover, the nurses appreciated that the prototypes reduced their patient-mobilization workload, facilitated patient empowerment, and improved their relationship with the patients. An attentive empathetic design approach can comprehend complex challenges of and subsequently design an effective solution for healthcare contexts, in which the stakeholders' medical necessities intertwine with emotional, psychological, behavioral, and sociocultural needs.

1159 Ring-Fenced Arthroplasty Unit: The Need of The Hour During Winter and A Pandemic Crisis

AimWinter pressures along with the COVID-19 pandemic, have caused cancellation of elective services, prolonged waiting times, patient dissatisfaction and financial implications. Length of stay (LOS) following joint replacements is variable. The availability of ring-fenced beds and enhanced recovery protocol (ERP) can improve these outcomes. The performance of a stand-alone arthroplasty unit in an acute NHS Trust was assessed regarding safety, LOS and complications.MethodPatient data was collected for total hip & knee replacements (TJAs) between the months of December to March of 2018-19 and 2019-20. Demographics, ASA, transfusion rates, LOS and 90-day reattendance was analysed. Modified ERP implemented in late 2019 included changes in analgesia and early post-operative mobilisation. The performance was then compared with DGHs within the region.ResultsIn 2019-20, of 280 TJAs performed, there was a mean LOS of 43 hours. This shows a reduction compared with LOS of 69 hours in 2018-19, where 288 TJAs were performed. In 2019-20, 74% of cases had early discharge within 36 hours of surgery, versus 24% in 2018-19. This accumulates to 333 inpatient days saved. Note that following ERP modification, 6 patients were discharged on the day of surgery. Surgery related complications within 3 months which required reattendance, were seen in only 2 patients. This unit performed an average of 335 TJA’s in these winter months, the highest average in comparison to other DGHs in the East Midlands region, which had an overall average of 165 cases.ConclusionsA ring-fenced arthroplasty service with adherence to ERP significantly decreases LOS and increases productivity.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study.

BackgroundThe Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult.ObjectiveWe report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic.MethodsWe divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%.ResultsA total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%).ConclusionsThis follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

Correction of medial compartmental osteoarthritis knee joint by high tibial closed wedge osteotomy with tension band wiring and cortical screw fixation in a rural set up

Introduction: Osteoarthritis of the Knee is a Chronic debilitating disease excessive pressure leads to breakdown of the cartilage matrix, architectural changes in the subchondral bone, further altering the joint geometry. Aims and Objective: The effect of TBW with 2 cortical screws in cases of uni-compartmental O.A. Knee joint 32 cases were studied. Result: Lateral wedge osteotomy done 1.5 cm distal to joint margin to avoid fracture of tibial plateau intraoperatively. Height of wedge is taken dependent on varus angle calculated from x-rays, for each degree 1 mm height of wedge is taken. 2 cortical screws fixed distal to osteotomy site. Conclusion: It is a cost effective technique with use of minimum hardware and early post operative mobilization in patients who cannot afford Knee Arthroplasty in a rural set up.

INTERNAL FIXATION OF TYPE I CAPITELLUM FRACTURE WITH HEADLESS SCREWS: A CASE REPORT

Background: Capitellum fractures are relatively rare. Distal humeral fractures that include capitellum and trochlea constitute approximately 6% of all distal humeral fractures and 1% of all elbow fractures. Despite the rarity of these injuries, an increasing number of clinical series have emerged, enhancing our understanding of these fractures.Case Report: A 26-year-old woman came to the emergency department with complaints of swelling and localized pain on the lateral side of her left elbow 2 hours after she fell off her motorcycle. Routine imaging such as plain radiographs and computed tomography scanning confirmed the fracture. She underwent open reduction and internal fixation surgery, stabilization of articular fragments with headless screws, and was fixated by a back slab and arm sling. The patient was also encouraged to do early elbow mobilization to avoid contractures and joint stiffness, routine follow-up every two weeks for a ROM evaluation. Preoperative Mayo Elbow-Performance Index score (MEPI) was 15, and postoperative 100.Discussion: The aim of capitellum fracture treatment is anatomical reconstruction and fixation to reduce the risk of non-union. In this case, we performed open reduction, secured two headless screws, which allow rigid fixation at the fracture site, provide fracture site compression through variable thread pitch design, and remained not removed later. These screws are suitable for use in anteroposterior and posteroanterior directions.Conclusion: The patient at two months follow-up has shown significant improvement. Accurate reduction, stable fracture fixation, and early postoperative mobilization were reported to provide good results with a MEPI score of 100.