Elective Orthopaedic Surgery Research Articles

457 Tourniquet Pressures in Orthopaedic Surgery - Is the Standard 250mmHg Safe?

Abstract Aim To determine safe levels of tourniquet inflation pressures in trauma and orthopaedic surgery. Method Data was collected on 150 patients retrospectively from the intraoperative and anaesthetic records of patients undergoing trauma and elective orthopaedic surgery at a single site. Data collected included demographic data, tourniquet inflation pressures and maximum intraoperative systolic blood pressures. British Orthopaedic Association (BOA) standards for safe intraoperative tourniquet use were used to determine safe tourniquet inflation pressures. Results The average maximum intraoperative systolic blood pressure was 125mmHg. In 134 cases (91%) the tourniquet pressure used was 250mmHg. Of the cases studied 54% of upper limb and 33% of lower limb tourniquets were overinflated when compared with BOA standards. Given the average maximum intraoperative systolic blood pressure, standard tourniquet inflation pressures of 200mmHg for upper limbs and 225mmHg for lower limbs should be used in preference to the more commonly used standard used pressure of 250mmHg. Conclusions All patients should ideally have an individual tourniquet pressure set based on their systolic blood pressure. However, if a standard pressure is to be used, values of 200mmHg for upper limbs and 225mmHg for lower limbs should be used in preference to 250mmHg as appears to commonly used currently.

A Comparative Study between Dexmedetomidine and Dexamethasone as Adjuvants to Bupivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Block in Upper Limb Surgeries

Abstract Background Brachial plexus blocks are among the most commonly performed peripheral nerve blocks for upper extremity surgeries in clinical practice. It offers many advantages over general anaesthesia for upper limb surgeries such as sympathetic block, better postoperative analgesia, high success rate and fewer side effects. Objective To compare the efficacy of bupivacaine plus dexamethasone versus bupivacaine plus dexmedetomidine as adjuvants on the block characteristics including: onset and duration of sensory and motor blockade, duration of postoperative analgesia, the first analgesic request time, adverse effect and hemodynamic parameters of patients. Patients and Methods After obtaining approval from the medical ethical committee in El Demerdash Ain Shams University Hospital, this study was conducted in El Demerdash Ain Shams University Hospital. It included patients scheduled for elective upper limb orthopedic and plastic surgery. A written informed consent was obtained from every patient after explaining the procedure. Results Regarding demographic data and operative characteristics there were no statistically significant difference between the two groups. The current study showed that the addition of dexmedetomidine to bupivacaine for supraclavicular brachial plexus block leads to prolongation of motor and sensory block duration, prolongation of duration of analgesia and decrease in total 24 hrs analgesia in comparative to dexamethasone. Conclusion Regarding comparison between dexmedetomidine and dexamethasone as an additive to bupivacaine in ultrasound guided supraclavicular block, it could be concluded that the addition of dexmedetomidine to bupivacaine shortened the onset times of both sensory and motor blocks, significantly prolonged their durations and prolonged the analgesia of brachial plexus block with subsequent consumption of less amounts of postoperative analgesics. Also the use of ultrasound guided technique decreased the incidence of complications such as pneumothorax or intravascular injection and hence, lowered the incidence of systemic toxicity of local anesthetics.

It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery

BackgroundWhile inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future.Materials and methodsIn a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed.ResultsA total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology.The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001.ConclusionThere is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.

Augmented Reality for Perioperative Anxiety in Patients Undergoing Surgery

Both augmented reality (AR) and virtual reality (VR) have had increasing applications in medicine, including medical training, psychology, physical medicine, rehabilitation, and surgical specialties, such as neurosurgery and orthopedic surgery. There are little data on AR's effect on patients' anxiety and experiences. To determine whether the use of an AR walkthrough effects patient perioperative anxiety. This randomized clinical trial was conducted at an outpatient surgery center in 2021 to 2022. All patients undergoing elective orthopedic surgery with the senior author were randomized to the treatment or control group. Analyses were conducted per protocol. Data analysis was performed in November 2022. AR experience explaining to patients what to expect on their day of surgery and walking them through the surgery space. The control group received the standard educational packet. The main outcome was change in State-Trait Anxiety Inventory (STAI) from the screening survey to the preoperative survey. A total of 140 patients were eligible, and 45 patients either declined or were excluded. Therefore, 95 patients (63 [66.3%] male; mean [SD] age, 38 [16] years) were recruited for the study and included in the final analysis; 46 patients received the AR intervention, and 49 patients received standard instructions. The AR group experienced a decrease in anxiety from the screening to preoperative survey (mean score change, -2.4 [95% CI, -4.6 to -0.3]), while the standard care group experienced an increase (mean score change, 2.6 [95% CI, 0.2 to 4.9]; P = .01). All patients postoperatively experienced a mean decrease in anxiety score compared with both the screening survey (mean change: AR, -5.4 [95% CI, -7.9 to -2.9]; standard care, -6.9 [95% CI, -11.5 to -2.2]; P = .32) and preoperative survey (mean change: AR, -8.0 [95% CI, -10.3 to -5.7]; standard care, -4.2 [95% CI, -8.6 to 0.2]; P = .19). Of 42 patients in the AR group who completed the postoperative follow-up survey, 30 (71.4%) agreed or strongly agreed that they enjoyed the experience, 29 (69.0%) agreed or strongly agreed that they would recommend the experience, and 28 (66.7%) agreed or strongly agreed that they would use the experience again. No differences were observed in postoperative pain levels or narcotic use. In this randomized clinical trial, the use of AR decreased preoperative anxiety compared with traditional perioperative education and handouts, but there was no significant effect on postoperative anxiety, pain levels, or narcotic use. These findings suggest that AR may serve as an effective means of decreasing preoperative patient anxiety. ClinicalTrials.gov Identifier: NCT04727697.

Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty

Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database. We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications. 22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS=0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P=.018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P=.019), and readmission (OR 2.82, 95% CI 1.19-6.67; P=.018) following outpatient TSA. Readmission was most often due to pulmonary complication (n=10, 22.7%). Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

Bone Health Management in Elective Orthopaedic Surgery: A Claims-Based Observational Study.

There are limited data on the management of bone health, including bone mineral density (BMD) evaluation and osteoporosis (OP) treatment, in patients undergoing elective orthopaedic surgeries. This was a retrospective cohort study using administrative claims data from Symphony Health, PatientSource for patients aged ≥50 years with documented kyphoplasty/vertebroplasty (KP/VP), total knee arthroplasty (TKA), and total hip arthroplasty (THA). Risk stratification to identify patients at very high risk for fracture (VHRFx) was based on clinical practice guideline recommendations to the extent information on variables of interest were available from the claims database. A total of 251919 patients met inclusion criteria: KP/VP (31018), TKA (149849), and THA (71052). The majority were female (80.3%) with a mean (SD) age of 68.5 (7.5) years. Patients undergoing KP/VP were older and had a greater comorbidity burden associated with risk for falls, mobility issues, muscle weakness, and respiratory and cardiovascular diseases. In the 6 months before surgery, 11.8% of patients were tested and/or received treatment for OP. Patients undergoing KP/VP were more likely to be tested and/or treated (17.5%) than patients undergoing TKA (11.0%) or THA (10.9%). Overall, men had a lower rate of testing and/or treatment than women (4.6% vs 13.5%). In the 12 months before surgery, patients with an OP diagnosis and at VHRFx (30.8%) had a higher rate of treatment and/or testing than those without OP (11.5%), or those without OP but with a fracture in the year preceding surgery (10.2%). Bone health management is suboptimal in patients undergoing elective orthopaedic surgeries and is worse in men than in women. Proper management of OP before and after surgery may improve outcomes.

Weekend versus Weekday Procedures for Total Hip Arthroplasties

AbstractThe “weekend effect” is the phenomenon that claims increased adverse outcomes for weekend procedures compared to weekday procedures. However, there is significant controversy regarding such disparities in elective orthopaedic surgeries. With the increasing demand for hip arthroplasty projected over the next 20 years, it is important to investigate a possible “weekend effect” to optimize outcomes and cost-effectiveness. In this study, we investigate the association between weekday versus weekend total hip arthroplasty (THA) and postoperative outcomes using the Healthcare Cost and Utilization Project (HCUP) data. We performed a retrospective analysis of the HCUP database between 2002 and 2020 comparing THAs done Monday to Friday versus THAs done Saturday to Sunday. Data collected included patient demographics and comorbidities, hospital length of stay, admission to procedure time, discharge disposition, mortality, and outcome data through postoperative day 30. THAs performed on weekends were associated with significantly increased length of stay, total charges, admission-to-procedure time, and mortality compared to those on weekdays. Our findings suggest that the development of nationwide programs to standardize care and weekend case management for THA patients can potentially help reduce health care costs, improve operative outcomes, and reduce the discrepancy between weekend and weekday surgeries.

Allied health professionals’ views on important outcomes of children’s elective lower limb orthopaedic surgery: a qualitative interview study to inform a core outcome set

Purpose A common methodological limitation of research that guides surgical procedure selection for children’s elective lower limb orthopaedic surgeries is inconsistent outcome selection. Improving outcome consistency can be achieved through the development of a core outcome set (COS). The aim of this study is to identify which outcomes are considered important for children’s elective lower limb orthopaedic surgeries by allied health professionals (AHPs) and explore why they select these outcomes, to inform a COS development project. Methods Online semi-structured interviews were conducted with relevant AHPs. Participants were selected using maximum variation purposive sampling; selection was based on profession and inpatient/outpatient role. The data set was analysed using an inductive and deductive approach to thematic analysis. Results Four physiotherapists, three orthotists, three prosthetists, and two occupational therapists were interviewed. Most identified outcomes of importance related to “activities and participation”. From the data, we conceptualised that AHPs with effective multidisciplinary communication focused on child-centred outcomes, while clinicians with limited multidisciplinary teamwork focused on role-based outcomes. Conclusions There is concurrence between outcomes identified as important in this study, and other qualitative studies in similar populations. These important outcomes were seldom measured in previous studies or in routine clinical practice. Implications for rehabilitation Allied health professionals (AHPs) prioritise activity and participation outcomes after children’s elective lower limb orthopaedic surgery. It is important to the rehabilitation of children after elective lower limb orthopaedic surgery that all involved AHPs collaborate with the wider multidisciplinary team. Multidisciplinary team communication encourages collaborative outcome identification, and discourages role defined outcome focus.

Intravenous iron and erythropoietin therapy for postoperative anemia among orthopedic surgery patients

BackgroundPostoperative anemia is a risk factor for adverse surgical outcomes. Our study aimed to assess the role of intravenous iron and erythropoietin therapy for the rapid correction of anemia following orthopedic surgery.MethodsPatients undergoing elective orthopedic surgery were prospectively enrolled and randomly divided into three groups: Control (placebo), Group 1 (IV iron monotherapy), and Group 2 [combined IV iron and recombinant human erythropoietin (rHuEPO) therapy]. Blood tests were performed preoperative (baseline) and on postoperative days (PODs) 1, 3, and 7.ResultsAll groups demonstrated significantly lower hemoglobin (Hb) concentrations compared to baseline, with no significant inter-group differences in postoperative Hb concentrations (p > 0.05). Serum erythropoietin, ferritin, and vitamin B12 levels, and reticulocyte count increased beyond normal ranges in all groups. Significantly lower serum iron levels were observed postoperatively in all groups (p < 0.05). No significant inter-group differences in hepcidin level were observed (p > 0.05).ConclusionPostoperative treatment with combined intravenous iron and rHuEPO was ineffective in correcting postoperative anemia among orthopedic surgery patients, besides achieving higher reticulocyte counts in the first week of surgery. No improvement in mobilization of storage iron was achieved with rHuEPO. We further suggest against vitamin B12 administration during the early postoperative period.

The use of Stimulan in bone and joint infections

AimsMusculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.MethodsBetween January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30).ResultsOverall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union.ConclusionOur multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications.Cite this article: Bone Jt Open 2023;4(7):516–522.

Healthy Eating for Elective Major Orthopedic Surgery: Quality, Quantity, and Timing.

Improvements to enhanced recovery pathways in orthopedic surgery are reducing the time that patients spend in the hospital, giving an increasingly vital role to prehabilitation and/or rehabilitation after surgery. Nutritional support is an important tenant of perioperative medicine, with the aim to integrate the patient's diet with food components that are needed in greater amounts to support surgical fitness. Regardless of the time available between the time of contemplation of surgery and the day of admission, a patient who eats healthy is reasonably more suitable for surgery than a patient who does not meet the daily requirements for energy and nutrients. Moreover, a successful education for healthy food choices is one possible way to sustain the exercise therapy, improve recovery, and thus contribute to the patient's long-term health. The expected benefits presuppose that the patient follows a healthy diet, but it is unclear which advice is needed to improve dietary choices. We present the principles of healthy eating for patients undergoing major orthopedic surgery to lay the foundations of rational and valuable perioperative nutritional support programs. We discuss the concepts of nutritional use of food, requirements, portion size, dietary target, food variety, time variables of feeding, and the practical indications on what the last meal to be consumed six hours before the induction of anesthesia may be together with what is meant by clear fluids to be consumed until two hours before. Surgery may act as a vital "touch point" for some patients with the health service and is therefore a valuable opportunity for members of the perioperative team to promote optimal lifestyle choices, such as the notion and importance of healthy eating not just for surgery but also for long-term health benefit.

Development and Validation of a Delirium Risk Prediction Model for Elderly Patients Undergoing Elective Orthopedic Surgery.

This study aimed to develop and validate a post-operative delirium (POD) nomogram in a population of elderly patients undergoing elective orthopedic surgery. A predictive model was developed based on a training dataset of 474 elderly patients undergoing elective orthopedic surgery from March 2021 to May 2022. POD was identified using the Confusion Assessment Methods (CAM). The least absolute shrinkage and selection operator (LASSO) method was used to screen risk factors, and prediction models were created by combining the outcomes with logistic regression analysis. We employ bootstrap validation for internal validation to examine the model's repeatability. The results were validated using a prospective study on 153 patients operated on from January 2022 to May 2022 at another institution. The predictors in the POD nomogram included age, the Mini-Mental State Examination(MMSE), sleep disorder, neurological disorders, preoperative serum creatinine (Pre-SCR), and ASA classification. The c-index of the model was 0.928 (95% confidence interval 0.898 ~ 0.957) and the bootstrap validation still achieved a high c-index of 0.912. The c-index of the external validation was 0.921. The calibration curve for the diagnostic probability showed good agreement between prediction by nomogram and actual observation. By combining preoperative and intraoperative clinical risk factors, we created a POD risk nomogram to predict the probability of POD in elderly patients who undergo elective orthopedic surgery. It could be a tool for guiding individualized interventions.

A dashboard proposal for pre-scheduling elective orthopedic surgeries in Brazil

The procedure for receiving materials from the CME - Material and Sterilization Center, begins after the surgery is released by the agreement together with the approval of the supplier, once this is approved, the delivery of the materials to be used in the hospital will commence. This delivery may take place hours or even a day before the scheduled date since the materials need to be washed and sterilized, and in some cases, there is a lack of a certain instrument that may cancel or even postpone the surgery that is only identified when the articles are opened while in the operating room and even with the patient undergoing anesthetic induction, bringing inconvenience to the patient, the medical team and the hospital. In this article we will be proposing the construction of a Dashboard to help reduce the errors or problems encountered during the scheduling of surgeries to be performed in Hospitals in Brazil, we are only dealing with Elective surgeries, those schedules that depend on third-party materials for their performance.

Prediabetes is associated with a higher serum neurofilament light chain level in adolescents.

Serum neurofilament light chain (sNfL) level, which is a biomarker indicative of neuroaxonal damage and cognitive impairment, has been reported in several neurological diseases. There has been a lack of studies on the association between sNfL levels and prediabetes in adolescents. This study investigated whether sNfL levels were higher in adolescents with prediabetes undergoing elective orthopedic surgery. The sNfL level was measured in 149 adolescents aged from 12 to 18 years who underwent elective orthopedic surgery at the Hunan Children's Hospital (18 with and 131 without prediabetes). We evaluated the association between prediabetes and sNfL level after adjusting for age, sex, and triglycerides using a multivariable linear regression model. The prevalence of prediabetes in adolescents was 12.08%. Univariate logistic regression analysis showed that prediabetes was related to sNfL. In multivariate logistic regression analysis, the association between prediabetes with sNfL levels remained significant after adjustment for age, sex, and triglyceride. The relationship between the two was further visualized by a smoothed curve. Prediabetes is associated with a higher sNfL. Further large-scale and prospective studies are needed to verify the clinical application of sNfL as a monitoring biomarker for adolescent prediabetes in adolescents and to evaluate the performance of sNfL in predicting the incidence of neuropathy and cognitive dysfunction in adolescents with prediabetes.

Post-traumatic stress and awareness in patient with traumatic lower limb surgery by neuraxial anesthesia: A randomized clinical trial

Aim of the studyAnesthesia decreases brain cognitive function, memory and pain, and also leads to the loss of consciousness. In this study, midazolam and propofol-sedated trauma patients undergoing lower limb surgery were evaluated for stress levels after neuraxial anesthesia.Subject or material and methodsThis double-blind randomized clinical trial was conducted on patients with lower extremity fractures due to trauma, who were candidates of elective lower extremity orthopedic surgery. Patients were randomly divided into two groups of propofol-sedated patients (n=110) and midazolam-sedated patients (n=110) after neuraxial anesthesia. Then, all patients underwent spinal anesthesia using 3 ml of 0.5% bupivacaine (3 mg/kg). Propofol (25-75 µg/kg/minute) was infused, and 1-2 mg of midazolam was injected PRN until patients reached the score of 3 on the Modified Observers' Assessment of Alertness/ Sedation Scale (MOAA/S).ResultsPreoperative sedation/alertness scores of patients in the two groups did not differ significantly from one another. Penetrating memories in the midazolam group was higher than the propofol group (P&lt;0.05). Personal relationship problem was more significant in the midazolam group than the propofol group (P&lt;0.05). Inability in controlling emotional feelings was higher in the midazolam group compared to the propofol group (P&lt;0.001).DiscussionOur findings indicated that a sub-hypnotic dose of propofol provided superior sedation and amnesia compared to midazolam. Aspects of stress, including penetrating memories, personal relationship problems, inability to control emotional feelings, and lack of depression during spinal anesthesia were better managed by propofol compared to midazolam.ConclusionsPropofol infusion was better in decreasing stress levels after surgery compared to midazolam.

447-P: Using the Cambridge Risk Score to Predict New Hyperglycemia and Complications in Surgical Patients without Diabetes

Perioperative hyperglycemia is associated with adverse surgical outcomes and increased mortality, and when occurring in patients without history of diabetes, this is termed new hyperglycemia (NH). The Cambridge Risk Score (CRS) is a screening tool for type 2 diabetes that is associated with NH, yet its application in a surgical population has not been studied. Our study examined the association between CRS, NH, and complications in patients undergoing elective surgery. In this retrospective cross-sectional study of adult surgical patients admitted to a tertiary care center over 4 years, subjects with NH (blood glucose ≥140 mg/dL in nondiabetics) were identified, and the CRS was calculated. CRS, NH, and clinical outcomes were adjusted for race/ethnicity, payor type, and Elixhauser Comorbidity Index. Patients were stratified by surgery type (cardiac/vascular, general, orthopedic, and neurologic), and multivariate regression analyses assessed the association between CRS, NH, and clinical outcomes. Of 10,531 subjects included in the study, 24% developed NH. After adjusting for covariates, the CRS was significantly associated with the development of complications (odds ratio [OR], 2.09 [1.69, 2.59]; p&amp;lt;.001) and NH (OR, 1.95 [1.66, 2.29]; p&amp;lt;.001). When stratifying by surgery type, CRS was significantly associated with NH, length of stay, and complications in the neurosurgery and orthopedic surgery cohorts, but not cardiac/vascular or general surgery. NH, when adjusted for covariates, was associated with 30-day readmission rates (OR, 1.52 [1.23, 1.86]; p&amp;lt;.001) and length of stay (linear model estimate, 0.61 [0.57, 0.66]; p&amp;lt;.001), but not with complication outcomes. CRS was associated with the development of NH and complications in elective neurological and orthopedic surgery patients and could help identify high-risk surgical patients. Further study should evaluate if treatment of NH is associated with better outcomes in CRS high-risk patients. Disclosure H.Lee: None. P.J.Hartfield: None. G.Sinson: None. M.C.Wang: Consultant; Medtronic, Zimmer Biomet. A.Z.Dawson: None. A.Thorgerson: None. C.E.Mendez: Speaker's Bureau; Siemens.

Comparison of the onset and duration of analgesia with intrathecal hyperbaric bupivacaine and intrathecal hyperbaric bupivacaine plus midazolam for lower limb orthopaedic surgeries.

Background: Various additive drugs have been added to bupivacaine to modify its onset and duration of analgesia; these include among others the use of midazolam, tramadol, morphine and fentanyl. This study, therefore, was aimed at comparing the onset and duration of analgesia during intrathecal hyperbaric bupivacaine 0.5% alone and intrathecal hyperbaric bupivacaine 0.5% with midazolam for lower limb orthopaedic surgeries. Methodology: This was a prospective randomized double-blinded controlled study that recruited one hundred and thirty-eight (138) ASA I and II patients scheduled for elective lower limb orthopaedic surgeries. The patients were allocated into two groups. Group BA (n=69) received 12.5mg(2.5mls) of 0.5% hyperbaric bupivacaine with 0.5mls normal saline intrathecally at L3-L4 or L4-L5 inter-space, and group BM that received 12.5mg (2.5mls) of 0.5% hyperbaric bupivacaine with 2.5mg (0.5mls) of preservatives-free midazolam at L3-L4 or L4-L5 intrathecally, no premedicants were given. Standard monitoring of the vital signs was done. The onset and duration of analgesia were documented and analysed. Results: Results showed that the mean onset time of analgesia was 37.04±4.53min and 25.65±4.84min in groups BA and BM respectively, with statistically significant difference (P &lt; 0.01). While the mean duration of analgesia were151.43 ± 58.84 min and 323.4 ± 22.55 min in groups BA and BM respectively, P&lt;0.01. Conclusion: The addition of 2.5mg (0.5ml) of midazolam to hyperbaric bupivacaine for subarachnoid block shortens the onset and prolonged the duration of analgesia when compared to bupivacaine alone.

A prolonged pandemic impacts the mental health of orthopaedic patients

Background and aims Majority of elective orthopaedic operations are postponed to accommodate the reallocation of healthcare resources to combat the pandemic. The aim of this paper is to evaluate the mental state of orthopaedic patients amidst limited orthopaedic management options. The secondary aim of this paper is to identify areas of significant stressors and to provide avenues for improvements. Methods A survey was administered on patients in outpatient clinics within a tertiary institution from 31 May to 13 June 2021 where government interventions prevented elective orthopaedic surgeries from being performed. Individuals' fatigue level were assessed with Chalder fatigue scale (CFS) and they were surveyed on their areas of stressors. Results A total of 160 orthopaedic patients (67 males and 93 females) were surveyed with an average age of 48.3 years old (range 17–88). 65 out of 160 (40.6%) were deemed to be severely fatigued (CFS &gt; 4) with a higher prevalence amongst females than males (47.3% vs 31.3% respectively.) The top three areas identified as stressors included transmitting to family/friends, travel restrictions/quarantine orders and limitation on recreational/social activities (67.5%, 45.6% and 57.5% respectively). 25.6% of the patients indicated that the increased difficulty in accessing healthcare was a stress factor. Discussion and conclusion There is a high proportion of severe fatigue amongst orthopaedic patients. Combined with postponement of orthopaedic care and treatment, the detrimental effects of a prolong pandemic can be more pronounced on orthopaedic patients. Identified areas of stressors provide avenues for improvements to safeguard the mental health of orthopaedic patients.

A Study of the Clinical Effects of Sequential Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Patients Undergoing Orthopedic Surgeries.

In orthopedic surgeries, there has been an increase in the usage of the neuraxial blockade to provide excellent surgical conditions and prolonged postoperative analgesia. The introduction of the sequential combined spinal epidural anesthesia (SCSEA) technique provides benefits for both spinal anesthesia (SA) and epiduralanesthesia. The focus of this study was to analyze the time needed to attain a desired level of sensory block, to compare the period of sensory block, and to study the intraoperative hemodynamics in the SCSEA and SA groups. The study was conducted on patients admitted for elective lower limb orthopedic surgeries. The sample size for this prospective randomized study is two groups of 67 subjects each. Patients aged between 18 and 65 years, posted for orthopedic surgeries for two to three hours, and of American Society of Anaesthesiologists (ASA) Grades 1 and 2 were included and divided into two groups. Group A patients received SCSEA with an epidural-test dose of 3 ml lignocaine (2%) with adrenaline and spinal bupivacaine (0.5%) of 1.5 ml-7.5 mg + fentanyl .25 mic if the sensory level was below T8. An epidural top-up was given with 2 ml per segment of 0.5% bupivacaine to bring the sensory level to T8. Group B patients received SA with spinal bupivacaine (0.5%) of 3 ml-15 mg + fentanyl .25 mic. Intraoperative hemodynamics, the duration to achieve a sensory level of T8, the time for two-segment regression of sensory block, and the complications that occurred were recorded. The study included a total of 134 subjects with each group having 67 subjects admitted for lower limb surgery. The mean value (SD) of the time taken to attain sensory block in the SCSEA group was prolonged when compared to the SA group (7.15 ± 0.75 and 5.01 ± 0.88). The time for two-segment regression in the SCSEA group was 86.77 ± 3.60and the SA group was 106.4 ± 8.01, which indicated that the SA group has a longer and better sensory block. Substantially, the study shows that the SCSEA group (P< 0.05) has better hemodynamics when compared to the SA group. The SCSEA technique has better intraoperative hemodynamic stability with a longer analgesic effect when compared to SA. SA shows a sudden change in hemodynamics but reveals a greatersensory block.

Risk factors and protective factors of acute postoperative pain: an observational study at a German university hospital with cross-sectional and longitudinal inpatient data

ObjectivesSurgical fear is one of the most important psychological risk factors for postoperative pain, but less is known about the contribution of protective factors. This study investigated somatic and psychological...