Elective Orthopaedics Research Articles

Prevalence and risk factors of preoperative anemia in patients undergoing elective orthopedic procedures in Northwest Ethiopia: a multicenter prospective observational cohort study

BackgroundPreoperative anemia is a common hematologic problem in major orthopedic surgery in developing countries. It is a condition in which the number and size of red blood cells are insufficient to meet the body’s physiologic needs, consequently impairing the capacity of the blood to transport oxygen to the body. Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. This study aimed to assess preoperative anemia prevalence and risk factors in patients undergoing elective orthopedic procedures.MethodA multicenter prospective observational cohort study was conducted from June 01 to August 30, 2022. A systematic random sampling technique was used to select the study unit. Data were collected using a structured questionnaire. Descriptive statistics were expressed in percentages and presented with tables and figures. Binary logistic regression was used to see the association between independent and dependent variables. A P-value < 0.05 was considered statistically significant.ResultPreoperative anemia’s prevalence and risk factors in patients undergoing elective orthopedic procedures was 24.1[95%CI= (18.2–30.6)]. Multivariable logistic analyses showed that low monthly income level [AOR:5,95%CI:(1.36–7.98)], patient with cancer [AOR:3.4,95%CI:(3.7–8.84)], patient with malaria infectious [AOR: 3.2,95%CI:( 1.13–8.91)], patient with anti-retroviral therapy [AOR: 5.2,95%CI:( 1.8-11.04)], and previous history of surgery [AOR:1,95%CI(1.43–2.4)], were factors significantly associated with preoperative anemia.ConclusionThe prevalence of preoperative anemia among adult patients who underwent elective orthopedics procedures was high. Low Monthly income, patients with cancer, patient with malaria infection, and patients with anti-retroviral therapy, previous histories of surgery were found significantly associated with preoperative anemia. So, we recommend to health professional’s early identification, diagnosis and treatment of preoperative anemia should be done to reduce the risks of anemia and related adverse outcomes.

In Vitro Evaluation of Vancomycin-Induced Toxicity in Human Primary Knee Chondrocytes.

Septic arthritis as a complication of orthopaedic joint surgery can have catastrophic outcomes for patients. To minimise infection risk associated with elective orthopaedics, topical vancomycin during surgery has become increasingly common. Evidence suggests that high concentrations of vancomycin, following direct application of the drug to the joint, are toxic towards various local cell types in the joint, including chondrocytes. However, the mechanism of this vancomycin tissue toxicity is yet to be determined. The aim of this study was to evaluate the toxicity of vancomycin on chondrocytes and the mechanisms of cell death involved. Human primary knee chondrocytes were exposed to vancomycin (1.25-10mg/mL) for 24h and their viability assessed using the resazurin reduction assay in vitro. Specific cell death mechanisms and their contributors, including reactive oxygen species (ROS) production and apoptosis, were measured. This study showed that high concentrations of vancomycin (5 and 10mg/mL) were toxic towards human primary knee chondrocyte cells, while lower concentrations (1.25 and 2.5mg/mL) were not. Cell death studies found that this occurred through an apoptotic pathway. This study provides additional support that vancomycin in high doses is toxic towards chondrocytes and preliminary evidence that this toxicity occurs via apoptotic cell death mechanisms.

Can Caregivers Forecast Their Child’s Postoperative Disability After Elective Orthopedic Surgery?

Can Caregivers Forecast Their Child’s Postoperative Disability After Elective Orthopedic Surgery?

HYPONATRAEMIA: THE ENEMY OF ENHANCED RECOVERY FOLLOWING PRIMARY HIP ARTHROPLASTY

Hyponatraemia is a potentially preventable post-operative complication following hip arthroplasty. There is a paucity of literature reporting its incidence and guidelines for prevention - unlike AKI which has been prioritised to great success. Hyponatraemia is now rife in elective orthopaedics causing multiple symptoms that delay ambulation and increase the length of hospital stay. We aim to assess the incidence of hyponatraemia and AKI as a benchmark following elective primary total hip arthroplasty (THA), as well as identify patients most at risk in a high volume arthroplasty centre.Between April 2018 and September 2018 all primary THA surgeries performed in one hospital were retrospectively reviewed. Pre-operative and 1 day post operative bloods were analysed. Patients included had normal pre-operative sodium.A total of 221 patients underwent THA. The mean age was 73.6 and ASA 2.1. No patients had a recorded AKI, however 42% of patients had a new post operative hyponatraemia. Of the hyponatraemia cases, 75% were mild, 18% were moderate, and 7% were severe. There was correlation between increased age and increased severity of hyponatraemia. The mean age of patients with mild hyponatraemia was 72.1, moderate was 77.7, and severe was 78.8. An association between ASA and severity of hyponatraemia was noted. In patients who had an ASA of 4 and hyponatraemia, 66% were moderate or severe, ASA 3 was 25%, ASA 2 was 24% and ASA 1 was 0%. The patients who had severe hyponatraemia received on average 3.5L fluid input perioperatively.Rates of post op hyponatraemia are significantly higher than AKI in primary THA. Severity of hyponatraemia increases with age and ASA. Due to its negative outcomes on recovery the high levels of hyponatraemia are worrying. We have identified which patient cohorts are more at risk and recommend more care should be taken in their perioperative fluid balance. It may be beneficial to consider successful AKI prevention and management campaigns and apply them to the prevention of hyponatraemia following hip arthroplasty.

There is a great variety of orthopaedic conditions presenting to a large hospital in Sierra Leone: a 3-year prospective study

PurposeIn Sierra Leone there is a large void in orthopaedic research into the type of orthopaedic injuries, both acute and chronic. Improved data collection is essential in providing insight to guide health care planning and research. This study aims to outline the types of orthopaedic injury sustained.MethodData were prospectively collected by local surgeons in the Orthopaedic outpatient department at a large hospital between January 2016 and January 2019.ResultsThe orthopaedic department saw a mean 728 patients per year, with mean age 24.0 years. The workload comprised of 64.92% acute orthopaedic conditions or their complications, with 35.08% elective orthopaedics. Fractures made up the largest proportion of clinical appointments, annually 244.33 fractures; however there was a high incidence of osteomyelitis.ConclusionThe study gives an important insight into the types and distribution of elective and trauma orthopaedic injuries sustained in Sierra Leone, which has not been previously reported, and highlights key areas where resources may be focused in order to improve clinical outcomes.

The Association Between Systemic Immune-Inflammation Index and Postoperative Cognitive Decline in Elderly Patients.

PurposePostoperative cognitive decline (POCD) is highly prevalent in elderly patients who received surgery. The systemic immune-inflammation index (SII) has been shown to be an independent predictor of many diseases associated with inflammation, but the relationship between the SII and POCD is unknown. We aimed to investigate the association between POCD and SII levels to examine the potential of SII in predicting POCD in elderly patients.Patients and MethodsThe present study was carried out among elderly patients who underwent elective orthopedics operation in our hospital, and SII, neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) were calculated from the admission blood sample. POCD was measured by Mini-mental State Examination (MMSE) in elderly patients. The association between SII levels and POCD was analyzed by binary logistic regression analysis.ResultsFinally, 19 (25%) of 76 patients were diagnosed with POCD. Compared with Non-POCD patients, POCD patients showed significantly higher levels of NLR, MLR, SII, especially SII at admission. SII was independently associated with the occurrence of POCD through the logistic regression analysis. Receiver operating characteristic curve analysis indicated that preoperative SII was a significant predictor for POCD, and the area under the curve was 0.909.ConclusionOur data suggest that preoperative NLR, MLR, SII levels in the blood are related to the occurrence of POCD. Preoperative SII level is a prognostic biomarker of POCD in elderly patients after orthopedics operation. More clinical studies are needed to further verify the value of SII in POCD.

A Safety Evaluation of the Resumption of Elective Orthopaedic Services in Higher Risk Patients During the COVID-19 Pandemic.

IntroductionThe COVID-19 pandemic has caused mass disruption to all aspects of society, with elective orthopaedics not spared. The pandemic has the potential to cause a tsunami of health burden in the community if elective services are not resumed to pre-pandemic levels of activity. Studies have shown that elective orthopaedics can be safely carried out in a COVID-19 free hospital. This study reviewed the transition in operating at an independent COVID-19 free hospital to an NHS hospital concurrently treating patients with COVID-19.MethodsA strategy of phased relaxation of clinical comorbidity criteria was followed. Patients from the orthopaedic waiting list were selected according to these criteria and observed recommended preoperative isolation protocols. Operations were undertaken in the independent sector under the COVID-19 contract and the NHS site. Patients were assessed from all phases in the resumption of services. In-hospital and post-operative complications with specific enquiries regarding the development of COVID-19 symptoms or the need and outcome for COVID-19 testing at 14 days and six weeks was recorded.ResultsThis study included 263 patients, of which 155 were female. The mean age of patients was 52.45. The mean BMI of all patients was 29.1 kg/m2. Additionally, 124 patients were American Society of Anesthesiologists (ASA) grade 1, 117 ASA grade 2 and 22 ASA grade 3 and 167 patients underwent a major operation, with total hip replacement being the most common operation. There were no in-hospital complications. No patients had a positive test result or symptoms of COVID-19 in the six-week post-operative period.ConclusionIn summary, we demonstrated that elective orthopaedic surgery can be safely undertaken via a green pathway in a higher risk patient cohort when COVID-19 is prevalent in the community.

Redesigning the Process for Scheduling Elective Orthopaedic Surgery: A Combined Lean Six Sigma and Person-Centred Approach.

The Health Service Executive Ireland model of care for elective surgery supports the delivery of elective surgical care in achieving both process and clinical outcomes. This project was conducted in the Orthopaedic Department. Following an outpatient consultation with an orthopaedic surgeon, patients who required surgical intervention were scheduled for their intervention by the administrative team. Prior to commencing this project, the average time from patient consultation to being scheduled for surgery on the hospital system was 62 h/2.58 days. A pre- and post-team-based intervention design employing Lean Six Sigma methodology was applied to redesign the process for scheduling elective orthopaedic surgery. The project was informed by collaborative, inclusive, and participatory stakeholder engagement. The goal was to streamline the scheduling process for elective orthopaedic surgery, with a target that 90% of surgeries are scheduled “right first time” within 48 h/two working days of the outpatient consultant appointment. The main outcome measures showed that 100% of orthopaedic surgeries were scheduled successfully within 2 days of outpatient appointment. Duplication in work between patient services and scheduling teams was eliminated and facilitated a reduction in unnecessary staff workload. This project highlights the importance of collaborative interdisciplinary stakeholder engagement in the redesigning of processes to achieve sustainable outcomes, and the findings have informed further improvements across the hospital’s surgical scheduling system.

Minimally invasive hallux valgus correction: Is it better than open surgery?

BackgroundThe aim was to compare the minimally invasive (MIS) chevron osteotomy to the well-established open chevron osteotomy for the correction of hallux valgus deformity. MethodsTwo retrospective cohorts of patients treated with MIS or open chevron osteotomy for hallux valgus correction, matched for age and gender with a minimum follow up of six months were reviewed. Functional outcomes were evaluated using pre and post-operative Manchester Oxford Foot and Ankle Questionnaire (MOXFQ), Visual Analog Score (VAS) for pain and the Unified Elective Orthopaedic Score (UnEOS). Two independent, blinded examiners evaluated the radiographic correction of hallux valgus (HV) and intermetatarsal (IM) angle. ResultsA Total of 54 cases (27 per study group) with a mean follow-up of 25.9 months were included in the study. Pre-operatively, VAS (p = 0.76) and MOXFQ (p = 0.46) scores and HV angle (p = 0.1) were comparable in both groups. However, IM angle was significantly larger in the MIS group (p = 0.005). Post-operatively there was significant improvement in VAS and MOXFQ scores as well as significant correction of the HV and IM angles (p < 0.0001) for both groups. Comparing the two procedures, there was no significant difference between groups for VAS (p = 0.34), MOXFQ scores (p = 0.56) and HV angles (p = 0.069) but the MIS technique was significantly better in improving the IM angle (p = 0.016). The post-operative UnEOS score and the Satisfaction UnEOS domain reached excellent levels for the entire cohort with no statistical difference between the two groups (p = 0.2 and 0.28 respectively). ConclusionResults show MIS chevron osteotomy provides better radiographic correction of the IM angle but functional outcomes for all parameters were comparable to the open technique. It can therefore be considered at least equivalent to standard open surgery when compared using validated Patient Reported Outcome Measures (PROMs).

605 Group and Save Sampling in Total Knee and Hip Arthroplasty: Is It Necessary?

Abstract Aim To induce a change in practice with regard to pre-op G&amp;S sampling. This is common practice in elective orthopaedics. Transfusion rates are negligible. Therefore, omitting this practice can reduce the financial burden on the Trust. Method Patient's undergoing elective primary total knee or hip arthroplasty over a 1-year period were retrieved from a database. Data regarding pre/post-op haemoglobin levels and transfusion status was obtained from patient case notes and Trust ICE pathology reporting system. Results There were a total of 454 patient's (251 undergoing TKR, 203 undergoing THR). Four patient's (1.6%) in the TKR group and 11 patient's (5.4%) in the THR group required transfusion. Of these patient's, 5 had cardiac problems and 6 had pre-operative anaemia. Conclusions Routine G&amp;S sampling is unnecessary in the majority of cases and should only be reserved for certain cases (patient's with significant cardiac problems and those with a transfusion history). Patient's with pre-operative anaemia should have optimisation of haemoglobin level prior to the procedure.

Preoperative Serum Metabolites and Potential Biomarkers for Perioperative Cognitive Decline in Elderly Patients.

Perioperative cognitive decline is one of the perioperative neurocognitive disorders common to see in elderly patients. Although POCD increases patient mortality and hospitalization time, the exact inflammatory and related mechanisms are still unknown. Besides, the diagnosis of POCD lacks a unified and straightforward evaluation neuropsychological scale. Metabolites could reveal chemical fingerprints left behind by the cellular process, which provides a new aspect to understand the biological process behind. According to the post-operative MMSE score, 56 patients who received elective orthopedics surgery were included and divided into POCD and Non-POCD groups. Preoperative serum metabolites in both groups and post-operative serum metabolites were analyzed. We then performed an SVM model using 10 differential metabolites in preoperative samples as features to evaluate the patients' risk of POCD, which appeared to be positively associated with POCD and could be a potential biomarker. We also analyzed differential serum metabolites from preoperative and post-operative samples of POCD patients. By analyzing their overlap differential metabolites with between POCD and Non-POCD patients, we further inferred seven metabolites positively related to the POCD mechanism. Our results provide a more convenient method to aid POCD diagnosis and prevention using biomarkers and explore the possible mechanism behind.

Public Interest in Elective Orthopedic Surgery Following Recommendations During COVID-19: A Google Trends Analysis

IntroductionPrecautions issued by organizations such as the American Academy of Orthopaedic Surgeons (AAOS) recommending against any elective, or non-essential, surgical procedures have significantly affected healthcare resource utilization by the public during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In this study, we demonstrate the value of the Google Trends (GT) interface to characterize and monitor in real-time the response in public interest toward various elective orthopedic procedures.MethodsSearch volume databases were generated from January 2015 to May 2020 for keywords related to anterior cruciate ligament (ACL) reconstruction, elbow arthroplasty, hip arthroplasty, knee arthroplasty, and rotator cuff repair. To measure the immediate effects on public interest, the percent change was calculated from the AAOS, and Centers for Medicare and Medicaid Services (CMS) defined a 30-day pre-recommendations period to a 30-day post-recommendations period. To measure long-term effects, mean search volumes from January 1, 2015, to February 29, 2020, were compared to mean search volumes from March 1, 2020, to May 21, 2020.ResultsIn the 30-day period following statements by the AAOS and CMS, interest in all search terms except “partial knee arthroplasty” decreased as follows: “ACL reconstruction” (-32.7%); “ACL repair” (-22.6%); “anterior cruciate ligament reconstruction” (-39.8%); “elbow arthroplasty” (-17.2%); “elbow joint replacement” (-15.1%); “total elbow arthroplasty” (-40.0%); “hip arthroplasty” (-23.0%); “hip replacement” (-41.2%); “total hip arthroplasty” (-23.0%); “knee arthroplasty” (-43.0%); “total knee arthroplasty” (-33.3%); “rotator cuff repair” (-34.2%); “rotator cuff surgery” (-50.6%); “shoulder arthroplasty” (-26.7%).DiscussionGT data have previously demonstrated utility in characterizing and anticipating shifts in real-world healthcare utilization, making it an invaluable tool for physicians to anticipate and address the emerging needs of our patient population. Our study further illustrates the value of GT in localizing rapidly recovering interest in several of the most common elective orthopedic surgeries, enabling surgeons with up-to-date actionable data to guide the management of practices and healthcare facilities as the US slowly emerges from precautions endorsed during the COVID-19 pandemic.

Objective assessment of the efficacy of telephone medicine consultations in dispensing elective orthopaedic care using a novel scoring tool

BackgroundTelemedicine consultations have increased significantly as a result of the COVID-19 pandemic. As remote consultations have been employed across specialities, there has been limited analysis of their efficacy. The goal of this study is to objectively assess if telephone medicine is valuable for clinical consultations in elective orthopaedics using a novel scoring tool. MethodsA literature review and survey were performed to determine the objectives of a specialist consultation. Based on the results, a four-component scoring system was developed with a set of guidelines. Eighty telephone consultation letters from a hip and knee clinic were scored by two independent observers. The results were compared and the guidelines were clarified. Clinic letters from previous face to face consultations from the same clinic were scored and compared to telephone medicine letters. The inter-observer reliability was calculated using Cronbach's Alpha. ResultsThe mean score of the telephone consultations was 7.3 as compared to 7.9 (Maximum possible score-8) with face to face consultations. Second opinion referrals scored the least when consulted over the telephone, while follow-up patients both pre-operative and post-operative scored similar to face to face consultations. The inter observer reliability co-efficient was more than 0.8 for every component of the score suggestive of good reliability. ConclusionsThis study identifies the areas where telephone medicine can make a valuable contribution to making diagnosis and treating orthopedic patients. We plan to use this to stratify future clinic appointments. The score is a simple, concise and reliable tool whose role may not be limited to orthopaedics but can be extended to other medical fields.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery.

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

Polypharmacy After Elective Orthopedic Surgery.

Polypharmacy After Elective Orthopedic Surgery.

Polypharmacy After Elective Orthopaedic Surgery

Polypharmacy is common, especially among older patients. Polypharmacy can lead to adverse patient outcomes and increased healthcare costs. After elective hip or knee arthroplasty, several new medications are prescribed, which can contribute to polypharmacy, although these medications are necessary in the postoperative period. Although some instances of polypharmacy may be appropriate, many are not. Nurse practitioners play a vital role in identifying and preventing inappropriate polypharmacy in the postoperative period and can develop individualized therapy plans for each patient to provide safe medication use in patients. This would be beneficial in the orthopaedic surgery postoperative period because of the introduction of several new medications.

The bone prone team

When the COVID-19 pandemic arrived in the United Kingdom, elective orthopaedics was halted. This article tells the tale of the orthopaedic surgeons who rose to the challenge of helping to treat coronavirus patients on the intensive care unit.

Reemergence of Multispecialty Inpatient Elective Orthopaedic Surgery During the COVID-19 Pandemic

Reemergence of Multispecialty Inpatient Elective Orthopaedic Surgery During the COVID-19 Pandemic

Perioperative Gabapentin or Pregabalin with Elective Orthopedic Surgery

Increasingly, surgeons are prescribing gabapentin or pregabalin to prevent or relieve postoperative pain, with the intent of limiting postoperative

Influence of Different Connecting Rod Configurations on the Stability of the Ilizarov/TSF Frame: A Biomechanical Study.

AimThe Ilizarov external fixator (IEF) is frequently used in trauma and elective orthopaedics. Many of its biomechanical variables (ring size, wire diameter, wire number, half pins vs wires, etc.) and their influence on stability and stiffness have been investigated. There is, however, a paucity in the literature regarding the influence of the connecting rod numbers and configurations between the rings on IEF stability. The primary aim of this biomechanical study was to compare the stability between four- and three-rod IEF configurations. Secondarily to assess the difference in stability between symmetrical and asymmetrical spacing of the IEF rods.Materials and methodsA custom jig was designed to facilitate mounting of a basic two-ring IEF in a hydraulic press. Controlled centre and off-centre (thus simulated bending) axial loading was then applied across the frame. The configurations were loaded up to 4,000 N. The frame deformation was plotted and the data were then analysed and interpreted.ResultsNegligible differences were observed between different four- and three-rod configurations as long as the applied force at the loading point (LP) was within the area of support (AOS) created by the rods. The different four-rod constructs were always more stable than the three-rod constructs during bending.ConclusionThere is comparable stiffness between a four-rod and a three-rod IEF construct as long as the LP is within the AOS created by the rods. A four-rod IEF is stiffer than a three-rod IEF in bending.Clinical significanceThis study will possibly change some paradigms regarding the planning and application of IEFs by Orthopaedics Traumatologists and Reconstruction Surgeons.How to cite this articleThiart G, Herbert C, Sivarasu S, et al. Influence of Different Connecting Rod Configurations on the Stability of the Ilizarov/TSF Frame: A Biomechanical Study. Strategies Trauma Limb Reconstr 2020;15(1):23–27.