Elective Hip Replacement Surgery Research Articles

ENHANCING ELECTIVE SURGERY MANAGEMENT WITH OPENPREDICTOR: VALIDATION OF A CLINICAL DECISION AID FOR OPTIMIZING ELECTIVE PATHWAYS

OpenPredictor, a machine learning-enabled clinical decision aid, has been developed to manage backlogs in elective surgeries. It aims to optimise the use of high volume, low complexity surgical pathways by accurately stratifying patient risk, thereby facilitating the allocation of patients to the most suitable surgical sites. The tool augments elective surgical pathways by providing automated secondary opinions for perioperative risk assessments, enhancing decision-making. Its primary application is in elective sites utilising lighter pre-assessment methods, identifying patients with minimal complication risks and those high-risk individuals who may benefit from early pre-assessment.The Phase 1 clinical evaluation of OpenPredictor entailed a prospective analysis of 156 patient records from elective hip and knee joint replacement surgeries. Using a polynomial logistic regression model, patients were categorised into high, moderate, and low-risk groups. This categorisation incorporated data from various sources, including patient demographics, co-morbidities, blood tests, and overall health status.In identifying patients at risk of postoperative complications, OpenPredictor demonstrated parity with consultant-led preoperative assessments. It accurately flagged 70% of patients who later experienced complications as moderate or high risk. The tool's efficiency in risk prediction was evidenced by its balanced accuracy (75.6%), sensitivity (70% with a 95% confidence interval of 62.05% to 76.91%), and a high negative predictive value (96.7%).OpenPredictor presents a scalable and consistent solution for managing elective surgery pathways, comparable in performance to secondary consultant opinions. Its integration into pre-assessment workflows assists in efficient patient categorisation, reduces late surgery cancellations, and optimises resource allocation. The Phase 1 evaluation of OpenPredictor underscores its potential for broader clinical application and highlights the need for ongoing data refinement and system integration to enhance its performance.

Risk and complication profiles of orthogeriatric patients in elective hip and knee joint replacement

The care of geriatric patients undergoing elective orthopedic surgery is becoming increasingly more important due to demographic trends. Compared to geriatric traumatology, however, there are still no established orthogeriatric care models in Germany and therefore hardly any scientific data. The aim of this study was to describe the risk and complication profiles in older patients with elective hip and knee replacements. In aprospective study data were collected from orthogeriatric patients with indications for elective hip and knee replacement surgery who fulfilled defined inclusion and exclusion criteria between January 2021 and August 2023 in the orthopedic department of aGerman university hospital for the descriptive analysis of risk and complication profiles. In addition to apreoperative and perioperative data analysis, afollow-up was conducted 4-6weeks and 3months postoperatively. The surgical risk profile of the patient population analyzed was characterized by advanced age (78.4 ± 4.8years), preobesity/obesity (76%), multimorbidity (7.4 ± 3.1 comorbidities), polypharmacy (7.5 ± 3.8 medications), immobility (short physical performance battery 7.1 ± 2.6), prefrailty/frailty (87%), frequent anticoagulation (22%) and ahigh number of potentially inappropriate medications (64%). Complication events mainly occurred within the first 7days postoperatively and 90% of the events within this recording period were minor complications. The overall complication rate significantly decreased in the follow-up period. Due to the high risk and complication profiles the routine use of orthogeriatric co-management models for elective orthopedic surgery should be considered in the future.

β-hydroxybutyrate exposure restores mitochondrial function in skeletal muscle satellite cells of critically ill patients

Background and AimDysfunction of skeletal muscle satellite cells might impair muscle regeneration and prolong ICU-acquired weakness, a condition associated with disability and delayed death. This study aimed to elucidate the distinct metabolic effects of critical illness and β-OHB on satellite cells isolated from these patients. MethodsSatellite cells were extracted from vastus lateralis muscle biopsies of patients with ICU-acquired weakness (n = 10) and control group of healthy volunteers or patients undergoing elective hip replacement surgery (n = 10). The cells were exposed to standard culture media supplemented with β-OH-butyrate to assess its influence on cell proliferation by ELISA, mitochondrial functions by extracellular flux analysis, electron transport chain complexes by high resolution respirometry, and ROS production by confocal microscopy. ResultsCritical illness led to a decline in maximal respiratory capacity, ATP production and glycolytic capacity and increased ROS production in ICU patients’ cells. Notably, the function of complex II was impaired due to critical illness but restored to normal levels upon exposure to β-OH-butyrate. While β-OH-butyrate significantly reduced ROS production in both control and ICU groups, it had no significant impact on global mitochondrial functions. ConclusionCritical illness induces measurable bioenergetic dysfunction of skeletal muscle satellite cells. β-OH-butyrate displayed a potential in rectifying complex II dysfunction caused by critical illness and this warrants further exploration.

Individual Factors Modifying Postoperative Pain Management in Elective Total Hip and Total Knee Replacement Surgery.

Total hip and knee replacements are the most common orthopedic procedures performed due to osteoarthritis. Pain is an intrinsic symptom accompanying osteoarthritis, persisting long before surgery, and continuing during the preoperative and postoperative periods. Appropriate pain management after surgery determines the comfort, duration, and cost of hospitalization, as well as the effectiveness of postoperative rehabilitation. Individual differences in pain perception and tolerance in orthopedic patients remain an important research topic. Therefore, the aim of this study was to investigate the predictors of analgesic requirements (morphine, acetaminophen, and ketoprofen), including individual pain threshold and tolerance, body mass index (BMI), diabetes, and beliefs about pain control in patients undergoing elective hip or knee arthroplasty using a multilevel regression model (N = 147, 85 women, 62 men, 107 after hip replacement, and 40 after knee replacement). Results: Higher pain tolerance was associated with a lower dose of morphine per kg after surgery. Patients undergoing hip surgery received a lower dose of ketoprofen than patients undergoing knee surgery. The more the patient believed in personal pain control, the stronger the negative relationship between pain tolerance and morphine requirement. The lowest doses were given to patients with the highest pain tolerance and the greatest belief in personal control. Factors such as belief in pain control and pain tolerance should be considered in comprehensive postoperative pain management in orthopedic patients to reduce opioid doses and, thus, side effects.

The impact of restricted provision of publicly funded elective hip and knee joints replacement during the COVID-19 pandemic in England.

Elective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery. We included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016-2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic. We included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic. The restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements.

The Aging Bone Marrow Niche Disrupts Glutamine Metabolism By Upregulating HSC Derived Glutamine Synthetase

As our aging population grows it is becoming increasingly important to better understand the physiological changes that drive that drive the aging process. Aging has long been known to drive haematopoietic stem cell (HSCs) dysfunction and therefore has been implicated in promoting the development of age-related haematopoietic diseases, such as leukaemia and myeloma. It is likely that a combination of intrinsic changes within the HSCs and extrinsic changes within the bone marrow (BM) microenvironment contribute to HSC aging. We have previously shown that the bone marrow niche accumulates senescent cells which contribute to impaired HSC response to stress 1. Here we investigate the intrinsic changes that can be observed in aged HSCs and how these are influenced by the bone marrow niche. In order to investigate the intrinsic changes that drive metabolic HSC aging we BM was isolated from young (8-12 weeks) and aged (18-24 months). Single HSCs were then FACS purified and sequenced using the SmartSeq2 protocol. Three transcriptionally distinct populations were identified, HSCs from young mice (Y), HSCs from aged mice with an aging transcriptional signature (O) and HSCs from aged mice that are transcriptionally similar to HSCs from young mice (OY). Assessment of differentially expressed genes between these three populations revealed that glutamine synthetase ( glul) is significantly upregulated in the O population compared to both the Y and OY population. Glul is responsible for the conversion of glutamate to glutamine and therefore levels of both were next measured in FACS purified HSCs from aged and young mice. Results show that whilst there was no difference in glutamate levels, the glutamine levels were significantly reduced in HSCs from aged mice. These data suggest that glutamine metabolism is impaired in aged HSC. Next, to determine the impact of the aged BM niche on glul expression in aged HSCs, HSCs from young and aged PepCboy (CD45.1+) mice were FACS purified and adoptively transferred into young C57Bl/6 mice. After 12 weeks the mice were sacrificed and engraftment of CD45.1+ cells was confirmed by flow cytometry. In addition CD45.1+ HSCs were FACS purified to assess glul expression and measure glutamine and glutamate levels. Results confirm that the mechanism for changes in glul expression and glutamine levels is driven by the aging BM niche and transplantation into a young niche reverses this change. To understand the importance of dysregulated glutamine metabolism in aged humans we collected BM from older patients undergoing elective hip replacement surgeries. All samples were collected following informed consent and under approval of the UK NHS Health Research Authority (ref07/H0310/146). CD34+ cells were isolated and RNA extracted to measure glul expression. Similarly, to data from aged mice glul expression was elevated in aged CD34+ cells compared to young CD34+ controls. Furthermore, glutamine levels were also low in aged CD34+ cells. This suggests that the changes in HSCs from aged mice correlate with finding in human stem cells and mice are therefore a suitable species to study dysregulated glutamine metabolism in aged HSCs. Together this work demonstrates that aging causes a disruption of glutamine and glutamate metabolism in HSCs. The cause for this disruption and its direct consequences on overall HSC metabolism remains to be explored. However, it is likely that these metabolic changes will have a knock-on effect on HSC function and may elucidate some of the drivers of metabolic HSC aging.

Detection and Prevention of ADAR1p150-Induced Hematopoietic Stem and Progenitor Cell Aging

Introduction: Over the last decade, ADAR1p150 has been linked by our research team and others to malignant progenitor reprogramming and therapeutic resistance in a broad array of malignancies. However, ADAR1p150's role in accelerated hematopoietic stem and progenitor cell (HSPC) aging in response to inflammatory cytokines had not been clearly elucidated. Here, we investigate ADAR1 splice isoform switching and the ADAR1p150 inhibitory effects of Rebecsinib on human HSPC function in normal humanized aged normal bone marrow (aNBM) HSPC mouse models. Methods: Whole transcriptome RNA sequencing (RNA-seq) was utilized with splice isoform and editome analysis to detect ADAR1 splice isoform switching and adenosine to inosine RNA editing. Rebecsinib (17S-FD-895), a pre-IND drug candidate, has shown promising potential as an inhibitor of ADAR1p150-mediated RNA editing ( Crews, Ma...Jamieson. Cell Stem Cell 2023), which is an important therapeutic target in patients with myelofibrosis or acute myeloid leukemia that overexpress ADAR1p150 compared with ADAR1p110. Human CD34 + cells, isolated from aged normal bone marrow (aNBM) from patients undergoing elective hip replacement surgery, were transduced with a lentiviral ADAR1-nano-luciferase reporter and transplanted into NSG-SGM3 adult mice that secrete human SCF, IL-3, and GM-CSF cytokines that support normal hematopoiesis. After engraftment confirmation peripheral blood human CD45 flow cytometric assessment and IVIS 200 system imaging of ADAR1-nano-luc-GFP reporter expressing HSPC engraftment, the mice were randomly divided into vehicle-treated and Rebecsinib-treated groups (15mg/kg, twice a week for two weeks). Peripheral blood, bone marrow, and spleen were collected upon treatment completion for analysis. Results: By HSPC RNA-seq, we detected an imbalance between ADAR1p150 and ADAR1p110 expression together with increased RNA editing and splicing alterations using whole transcriptome RNA sequencing (RNA-seq) of aged compared with young bone marrow hematopoietic stem and progenitor cells (HSPCs). However, the functional relevance of ADAR1 splice isoform switching had not been evaluated in human-aged normal bone marrow HSPC xenograft (PDX) mouse models nor had this cytokine-induced HSPC aging been reversed. Flow cytometric analysis and immunohistochemistry staining revealed that Rebecsinib treatment at a dose of 10mg/kg, twice a week for two weeks, effectively spared normal human immune cells (CD3+, CD14+, and CD19+ cells). Remarkably, Rebecsinib treatment not only preserved Hematopoietic Stem (CD34+CD38-) cells and Progenitor (CD34+CD38+) cells in peripheral blood, bone marrow, and spleen but also promoted their expansion. These findings demonstrate the potential of Rebecsinib to enhance the retention of HSPC populations in the bone marrow niche. Conclusions: Our pre-clinical experiments utilizing RNA-seq, a novel ADAR1-nano-luciferase-GFP reporter, and aNBM PDX mouse models provide compelling evidence supporting the potential of Rebecsinib to restore the balance of ADAR1p150:p110 ratios and engraftment in humanized aNBM HSPC mouse models. These findings highlight Rebecsinib as a promising therapeutic candidate for targeting leukemia and myelofibrosis while preserving essential HSPC populations.

Retention of Urine after Elective Total Hip and Knee Replacement Surgeries - A Literature review

Urinary retention postoperatively is alarming complication that happened after elective hip and knee replacement surgeries. This literature review examined the incidence, risk factors, and management of postoperative urinary retention (POUR) in elective total hip and knee replacement surgery over the last five years.

A diarized journey: an interpretative phenomenological analysis of the older person’s lived experience of a hip or knee replacement within a fast-track programme

BackgroundFor the older person living with end-stage hip or knee osteoarthritis, a hip or knee replacement can be a traumatic event, influencing the physical, physiological, psychological, social and economic facets of daily living. This interpretative phenomenological study aimed to reveal and interpret the daily lived experiences of the older person before, during and after a primary total hip or knee replacement surgery in a fast-track programme in South Africa.MethodsA qualitative interpretive phenomenological study, collecting data through solicited diaries and reflexive member validation interviews from seven participants aged 65–75 years, who underwent a primary elective hip or knee replacement surgery. The surgical fast-track process and data collection process happened simultaneously. Data collection from the solicited diary started before surgery, continued during the surgery process and finished six weeks after surgery and this was followed with reflexive member validation interviews. Interpretative phenomenological analysis was used throughout the three phases of the fast-track programme.ResultsThree superordinate themes developed during the three phases of surgery: “The holistic impact of pain on daily quality of life”, “Finding ways to cope”, and “Transition between independence and dependence and back”. Although former research confirms the physical impact of osteoarthritis on the older person and the success of fast-track programmes for subsequent hip and knee replacements, this study contributes to the holistic impact of the surgery on participants’ daily lives. The diarized journey of individuals through the psychological, psychosocial, physical, professional, and spiritual experience are described and interpreted in this study.ConclusionsAcross the solicited diaries, it was clear that pain as catalyst impacted the daily activities of the individual physically, psychologically, and psychosocially. Pain was subjectively present at different intensities during all the phases of the replacement surgery, impairing mobilization and triggering roller-coaster emotions. In order to cope with physical and emotional difficulties while preparing and adjusting to the environment, participants reflected on social support, physical and professional support, and spirituality. Throughout the preparation, hospitalization and the recovery process, the transition between independence, dependence, and back to independence was significant, reinforcing the individual’s determination to recover.

The Accuracy of Digital Preoperative Templating in Primary Total Hip Replacements.

Background​ Digital templating is an essential part of preoperative planning in elective total hip replacement (THR) surgery. The goals of templating are to predict femoral and acetabular implant sizes, to assess leg length, offset, and implant positioning. Templating markers such as the KingMark device (Brainlab, Munich, Germany) have been developed to improve the accuracy. Although templating is commonly used in many centres, there are challenges related to the accuracy of the process, such as true magnification ideal positioning of the pelvis and hips/body habit (obesity). Objectives The aim of this study was to assess the accuracy of preoperative templating in THR patients, and to assess the difference between templating performed with and without the KingMark device. Methods​ Our retrospective study included 642 consecutive patients who had primary THR at the Royal Bournemouth Hospital in the UK. Four hundred fifty-three (71%) of patients had the KingMark device on their templated radiographs. Patients who had hybrid total hip replacements using an uncemented acetabular component and cemented femoral component were included in the study. Digital templating was done using TraumaCad software (Brainlab). Analysis of the accuracy of predicting component size has been evaluated by comparing preoperative planned sizes with implanted sizes as documented by the surgeons and labels attached to the operative note. ​ ​Results​ The templated size corresponded to the actual femoral implant used in approximately 65.2% of cases. When femoral prostheses within one size above or below the templated size were included,​the accuracy of preoperative templating rose to 97.2%. Regarding the uncemented acetabular component, the templated size corresponded to the actual acetabular implant used in 46.3% of cases. When acetabular cup within one size above or below the templated size were included, the accuracy of preoperative templating rose to 87.5%. Similarly, there was minimal difference between the predicted templated sizes using the KingMark device compared to templating performed without it. ​Conclusions​ Preoperative templating is an essential part in optimizing the outcome of THRs. Templating allows the surgeon to estimate the size of the components to be used. It also provides a starting point, from which the surgeon can proceed from, and saves valuable intraoperative time by assessing the level of the femoral neck osteotomy and the degree of lateral rasping. Multiple factors affect the accuracy of preoperative templating including the patient BMI, external rotation of the hip and surgeon's experience. Although there are different methods of templating, digital templating with 2D radiographs is likely the most cost-effective and efficient process available at this time.

Impact of pausing elective hip and knee replacement surgery during winter 2017 on subsequent service provision at a major NHS Trust: a descriptive observational study using interrupted time series

ObjectivesTo explore the impact of a temporary cancellation of elective surgery in winter 2017 on trends in primary hip and knee replacement at a major National Health Service (NHS) Trust,...

Empagliflozin-associated postoperative mixed metabolic acidosis. Case report and review of pathogenesis

BackgroundEuglycemic diabetic ketoacidosis associated with SGLT2 inhibitors is a rare, relatively new and potentially fatal clinical entity, characterized by metabolic acidosis with normal or only moderately elevated glycemia. The mechanisms are not fully understood but involve increased ketogenesis and complex renal metabolic dysfunction, resulting in both ketoacidosis and hyperchloremic acidosis. We report a rare case of fatal empagliflozin-associated acidosis with profound hyperchloremia and review its pathogenesis.Case presentationA patient with type 2 diabetes mellitus treated with empagliflozin underwent an elective hip replacement surgery. Since day 4 after surgery, he felt generally unwell, leading to cardiac arrest on the day 5. Empagliflozin-associated euglycemic diabetic ketoacidosis with severe hyperchloremic acidosis was identified as the cause of the cardiac arrest.ConclusionsThis unique case documents the possibility of severe SGLT2 inhibitor-associated mixed metabolic acidosis with a predominant hyperchloremic component. Awareness of this possibility and a high index of suspicion are crucial for correct and early diagnosis.

Effect of noradrenaline on propofol-induced mitochondrial dysfunction in human skeletal muscle cells

BackgroundMitochondrial dysfunction is a hallmark of both critical illness and propofol infusion syndrome and its severity seems to be proportional to the doses of noradrenaline, which patients are receiving. We comprehensively studied the effects of noradrenaline on cellular bioenergetics and mitochondrial biology in human skeletal muscle cells with and without propofol-induced mitochondrial dysfunction.MethodsHuman skeletal muscle cells were isolated from vastus lateralis biopsies from patients undergoing elective hip replacement surgery (n = 14) or healthy volunteers (n = 4). After long-term (96 h) exposure to propofol (10 µg/mL), noradrenaline (100 µM), or both, energy metabolism was assessed by extracellular flux analysis and substrate oxidation assays using [14C] palmitic and [14C(U)] lactic acid. Mitochondrial membrane potential, morphology and reactive oxygen species production were analysed by confocal laser scanning microscopy. Mitochondrial mass was assessed both spectrophotometrically and by confocal laser scanning microscopy.ResultsPropofol moderately reduced mitochondrial mass and induced bioenergetic dysfunction, such as a reduction of maximum electron transfer chain capacity, ATP synthesis and profound inhibition of exogenous fatty acid oxidation. Noradrenaline exposure increased mitochondrial network size and turnover in both propofol treated and untreated cells as apparent from increased co-localization with lysosomes. After adjustment to mitochondrial mass, noradrenaline did not affect mitochondrial functional parameters in naïve cells, but it significantly reduced the degree of mitochondrial dysfunction induced by propofol co-exposure. The fatty acid oxidation capacity was restored almost completely by noradrenaline co-exposure, most likely due to restoration of the capacity to transfer long-chain fatty acid to mitochondria. Both propofol and noradrenaline reduced mitochondrial membrane potential and increased reactive oxygen species production, but their effects were not additive.ConclusionsNoradrenaline prevents rather than aggravates propofol-induced impairment of mitochondrial functions in human skeletal muscle cells. Its effects on bioenergetic dysfunctions of other origins, such as sepsis, remain to be demonstrated.

Wait time management strategies at centralized intake system for hip and knee replacement surgery: A need for a blended evidence-based and patient-centered approach

ObjectivesDelays in access to specialty care and elective hip and knee total joint replacement (TJR) surgery remain a major concern among patients with osteoarthritis (OA) in Canada. Centralized intake systems as a wait time management strategy in the face of resource constraints can increase access and patient flow through the system but are not standard practice. We examine how wait time management strategies for the assessment and triaging referrals in a centralized intake system can inform quality improvement initiatives. DesignWe developed a discrete-event simulation model using all referrals to the Edmonton Bone and Joint Centre centralized intake system from 2012 to 2016 for the base case model. We assessed the combined effect of three wait time management strategies: improved prioritization, improved sorting through screening, and increased conservative management. Outcomes were measured in terms of patient flow and wait times. ResultsThe screener sees more patient referrals (7094 compared to 6922), and the number of patients who proceed to surgery is reduced by 282 patients (4%) in the wait time management scenario compared to the base case model. Wait times from referral to surgery are reduced by 54 days for surgical patients. Furthermore, urgent surgical patients experienced lower wait times in all stages of care than non-urgent patients, with wait times from referral to surgery reduced by 86 days. ConclusionsTriaging processes addressing prioritization, screening and conservative management of non-surgical patients can improve patient flow and significantly reduce patient wait times in a centralized intake process for TJR.

Transmuscular Quadratus Lumborum Block versus Infrainguinal Fascia Iliaca Nerve Block for Patients Undergoing Elective Hip Replacement: A Double-blinded, Pilot, Randomized Controlled Trial.

PurposeTransmuscular quadratus lumborum (TQL) block has been described as an effective option for postoperative analgesia in patients undergoing hip replacement with single injection described as providing analgesia for up to 24 h. We hypothesize that a TQL block, when compared to fascia iliaca block (FIB), will provide better analgesia and less motor block in the initial 24-h postoperative period.Patients and MethodsFifty patients undergoing elective hip replacement surgery, ASA I–III, were included in the study. Patients were randomized into two groups. Patients in group A received spinal anesthesia followed by FIB. Patients in group B received spinal anesthesia followed by TQLB. Postoperative pain scores and motor block were assessed at 6 and 24 hours. The primary outcome measure was 24 h total morphine consumption. Secondary outcome measures included pain score (VNS) and motor block (modified Bromage scale) at 6 and 24 h postoperatively.ResultsThere was no statistical difference in morphine consumption between the two groups (p-value 0.699). There was no difference in pain scores at 6 h (p-value 0.540) or 24 h (p-value 0.383). There was no difference in motor block at 6 h (p-value 0.497) or at 24 h (p-value 0.773).ConclusionTransmuscular quadratus lumborum block along with spinal anesthesia for patients undergoing elective hip replacement surgery does not reduce opioid consumption or motor weakness when compared to fascia iliaca block. The results and conclusion apply to a dose of 20 mL of 0.25% bupivacaine used in each group.

INDISCRIMINATE COAGULATION TESTING FOR BLEEDING RISK ASSESSMENT PRIOR TO ORTHOPEDIC SURGERY. IS IT A RATIONAL APPROACH?

Abstract Objective: Indiscriminative preoperative coagulation testing to identify patients at risk of bleeding is commonly practiced. However, this practice is no longer supported by current recommendations. We conducted this study with an aim to evaluate the advantage of doing screening testing for coagulation and hemostasis in unselected patients prior to elective orthopedic surgeries in our setting. Material and Methods: It was a retrospective, cross sectional study carried out at Medicare Cardiac and General Hospital, Jinnah Medical and Dental College, Karachi. All the patients admitted for elective orthopedic bilateral total knee replacement and Hip replacement surgeries from March 2016 to December 2018 were included in the study. Electronic data of patients’ pre-operative test results for Prothrombin time, activated partial Thromboplastin time was retrieved. Frequency of patients with deranged coagulation screening was calculated. Results: A total of 367 patients underwent pre-surgical coagulation testing. Male to female ratio was 1:3. Median age of patients was 61±5 years. A total of 2.9% (n=11) patients were found to have deranged coagulation profile. Out of which 3 patients did not undergo surgery and were loss to follow up. Out of total 0.54% (n=2) patients had both prolonged PT and APTT, 1.6% (n=6) patients had prolonged APTT and 0.3% (n=1) patient experienced intraoperative bleeding requiring one unit of packed cell transfusion. Only 0.3% (n=1) patient experienced post-operative bleeding and dropped her Hemoglobin and received transfusion. Conclusion: The overall results of the study suggest that indiscriminate coagulation screening does not provide any additional information unless further detailed hemostatic evaluation is carried out. It is suggested that routine screening tests should not be performed unless a medical history is indicative of bleeding tendency. Key Words: Coagulation screening, Bleeding risk, Orthopedic surgery.

Outpatient care through cross-sector prehabilitation and rehabilitation concepts in outpatient hip and knee arthroplasty

Kein noch so flammender Appell eines Gesundheitspolitikers hat alle Versorgungsstrukturen unseres Gesundheitssystems so zur Überprüfung eigener Effizienz und Einsparpotenziale gezwungen, wie das SARS-CoV‑2. Fast-Track-Chirurgie, lange vor der aktuellen Pandemie entwickelt, kann auch unter Einbindung verzahnter Versorgungsstrukturen ein unverzichtbares Element moderner Krankenhausroutinen werden. Durch deutlich kürzere Krankenhausverweildauern, sinkende Komplikationsraten sowie durch zusätzliche Stärkung der Eigenkompetenz und Motivation der betroffenen Patientinnen und Patienten, kann die Patientenzufriedenheit und das klinische Outcome verbessert werden. Krankenhauspersonal könnte entlastet und Gesamtkosten, auch durch Einbindung externer Prähabilitationszentren, gespart werden. Es gilt nun, weiter Standards zum Aufbau und zur Umsetzung entsprechend abgestimmter Prähabilitations- und Rehabilitationskonzepte bei geplanter endoprothetischer Versorgung von Hüft- und Kniegelenken zu entwickeln und idealerweise gleichzeitig Ressourcen durch regionale Vernetzung zu sparen.

Patterns and Persistence of Perioperative Plasma and Cerebrospinal Fluid Neuroinflammatory Protein Biomarkers After Elective Orthopedic Surgery Using SOMAscan.

The neuroinflammatory response to surgery can be characterized by peripheral acute plasma protein changes in blood, but corresponding, persisting alterations in cerebrospinal fluid (CSF) proteins remain mostly unknown. Using the SOMAscan assay, we define acute and longer-term proteome changes associated with surgery in plasma and CSF. We hypothesized that biological pathways identified by these proteins would be in the categories of neuroinflammation and neuronal function and define neuroinflammatory proteome changes associated with surgery in older patients. SOMAscan analyzed 1305 proteins in blood plasma (n = 14) and CSF (n = 15) samples from older patients enrolled in the Role of Inflammation after Surgery for Elders (RISE) study undergoing elective hip and knee replacement surgery with spinal anesthesia. Systems biology analysis identified biological pathways enriched among the surgery-associated differentially expressed proteins in plasma and CSF. Comparison of postoperative day 1 (POD1) to preoperative (PREOP) plasma protein levels identified 343 proteins with postsurgical changes ( P < .05; absolute value of the fold change [|FC|] > 1.2). Comparing postoperative 1-month (PO1MO) plasma and CSF with PREOP identified 67 proteins in plasma and 79 proteins in CSF with altered levels ( P < .05; |FC| > 1.2). In plasma, 21 proteins, primarily linked to immune response and inflammation, were similarly changed at POD1 and PO1MO. Comparison of plasma to CSF at PO1MO identified 8 shared proteins. Comparison of plasma at POD1 to CSF at PO1MO identified a larger number, 15 proteins in common, most of which are regulated by interleukin-6 (IL-6) or transforming growth factor beta-1 (TGFB1) and linked to the inflammatory response. Of the 79 CSF PO1MO-specific proteins, many are involved in neuronal function and neuroinflammation. SOMAscan can characterize both short- and long-term surgery-induced protein alterations in plasma and CSF. Acute plasma protein changes at POD1 parallel changes in PO1MO CSF and suggest 15 potential biomarkers for longer-term neuroinflammation that warrant further investigation.

Introducing Virtual Prehabilitation to a UK Elective Total Hip Replacement service to improve patient outcomes: An overview of the literature and proposed implementation plan

Elective Total Hip Replacement (THR) surgery is one of the most common elective surgeries in the UK, costing the National Health Service (NHS) over £300,000,000 annually. A review of the literature identified preoperative rehabilitation, known as ‘prehabilitation’, improves patient outcomes and decreases Length Of hospital Stay (LOS). This approach follows NICE guidelines which recommend prehabilitation for all patients undergoing joint replacement surgery. Challenges accessing prehabilitation classes at UK hospitals due to inadequate transport and COVID-19 restrictions present an opportunity to provide prehabilitation virtually. Physiotherapy services are increasingly utilising technology, in line with The NHS Long Term Plan to increase service accessibility. A review of the literature has established virtual prehabilitation is effective, feasible, and preferable for patients. Quality Improvement methodology has been used to propose an implementation plan for a virtual prehabilitation service. Further research is required to create a standardised prehabilitation protocol, and to assess the long-term effects and sustainability of virtual prehabilitation.

A decrease in serum 1,25(OH)2D after elective hip replacement and during bone healing is associated with changes in serum iron and plasma FGF23.

Although calcitriol is essential for bone healing, its serum concentrations are low after hip surgery, and they continue to decline during bone healing. This study aimed to test the hypothesis of an association of changes in calcitriol production with the status of fibroblast growth factor 23 (FGF23) and iron deficiency after elective hip replacement for coxarthrosis. In this prospective study, we measured the biomarkers of 17 patients undergoing elective hip replacement on admission, on the first day after surgery, and at the regular check-up after 48 ± 8days. The serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, transferrin, ferritin, parathyroid hormone, intact plasma FGF23 (iFGF23) and C-terminal FGF23 (cFGF23) were determined. In our patients who underwent elective hip replacement, significant correlations existed between the percent change in the conversion rate of 25(OH)D to 1,25(OH)2D, plasma intact to C-terminal FGF23 ratio, and serum iron. The production of calcitriol is compromised after elective hip replacement surgery, leading to reduced levels of active vitamin D in the serum. Significant correlations between the percent change in the conversion rate of 25(OH)D to 1,25(OH)2D, plasma intact to C-terminal FGF23 ratio, and serum iron on the first day as well as 7weeks after surgery could inspire future studies to determine whether and how calcitriol deficiency should be corrected, especially in fracture cases.