Elective Orthopaedic Patients Research Articles

General skin and nasal decolonization with octenisan® set before and after elective orthopedic surgery in selected patients at elevated risk for revision surgery and surgical site infections—a single-center, unblinded, superiority, randomized controlled trial (BALGDEC trial)

BackgroundThe preoperative body surface and nasal decolonization may reduce the risk of surgical site infections (SSI) but yields conflicting results in the current orthopedic literature.MethodsWe perform a single-center, randomized-controlled, superiority trial in favor of the preoperative decolonization using a commercial product (octenidine® set). We will randomize a total number of 1000 adult elective orthopedic patients with a high risk for SSI and/or wound complications (age ≥ 80 years, chronic immune-suppression, American Society of Anesthesiologists score 3–4 points) between a decolonization (octenisan® wash lotion 1 × per day and octenisan® md nasal gel 2–3 × per day; during 5 days) and no decolonization. Decolonized patients will additionally fill a questionnaire regarding the practical difficulties, the completeness, and the adverse events of decolonization. The primary outcomes are SSI and revision surgeries for postoperative wound problems until 6 weeks postoperatively (or 1 year for surgeries with implants or bone). Secondary outcomes are unplanned revision surgeries for non-infectious problems and all adverse events. With 95% event-free surgeries in the decolonization arm versus 90% in the control arm, we formally need 2 × 474 elective orthopedic surgeries included during 2 years.DiscussionIn selected adult orthopedic patients with a high risk for SSI, the presurgical decolonization may reduce postoperative wound problems, including SSI.Trial registrationClinicalTrial.gov NCT05647252. Registered on 9 December 2022.Protocol version: 2 (5 December 2022).

Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopaedic Surgery

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient’s buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.

Vitamin D and Albumin Deficiency in a Swiss Orthopaedic Surgery In-Patient Cohort.

Background: Vitamin D and protein deficiencies are common conditions in the general population. In Orthopaedic surgery, they can result in wound complications or poor bone healing. The goal of this study was, therefore, to determine the prevalence of vitamin D and albumin deficiencies in patients scheduled for elective Orthopaedic procedures. Methods: We performed an observational, noninterventional study using the demographic characteristics via means chart analysis of in-patients with an elective surgery in a single Swiss Orthopaedic centre. The following variables were collected and analysed: age, gender, BMI, ASA score, rate of vitamin D supplementation before surgery, and serum preoperative levels of vitamin D, albumin, Haemoglobin, calcium, and phosphate. Results: A total of 336 patients were analysed; there were 218 women (64.9%) and 118 men (35.1%). The average age was 59.4 years (17-89 years). The average BMI was 26.8 kg/m2 (17.8-37.6) and the average ASA score was II (I-III). The overall prevalence of vitamin D deficiency was 82.1%, being more common in the male (89.8%) than female patients (77.9%). Patients who received vitamin D supplements before surgery had an average vitamin D level in the normal range. Of the subgroup of 170 patients who were over 60 years of age, 78.8% of the patients were Vitamin D deficient, with deficiency once again being more common in men (93.3%) than in women (92%). Albumin deficiency was documented in 58.9% of the cases. A total of 62.8% of all the female patients were albumin deficient, and 51.7% of all male patients were. Of the subgroup of 170 patients who were over 60 years of age, 71.8% of the patients were albumin deficient, with the deficiency being practically identical in men (71.1%) and women (72%). Conclusions: Despite increased awareness in the medical community, vitamin D and albumin deficiencies remain highly prevalent in elective Orthopaedic patients. Pre/perioperative screening and addressing possible vitamin D and albumin deficiencies are of great importance for good outcomes in Orthopaedic surgery.

Preoperative comprehensive geriatric assessment and multidisciplinary team input in older people undergoing elective orthopaedic surgery: A feasibility trial.

To determine the feasibility of preoperative comprehensive geriatric assessment (CGA) and multidisciplinary team (MDT) input for older people undergoing elective orthopaedic surgery in a tertiary New Zealand setting. This single-centre retrospective study included elective orthopaedic patients older than 65 years (and Māori/Pasifika aged greater than 55 years) with hyperpolypharmacy, frailty, neurocognitive disorders and poor functional status. Patients attended a preoperative clinic where they had a geriatrician-led CGA along with MDT input. The feasibility of this preoperative model was assessed using outcomes of acceptability, accessibility and adherence. A qualitative description of patient demographics along with clinic assessment and interventions further describes this pilot experience. Sixty patients met inclusion criteria. This group were vulnerable older people (median age 77 years), with a high incidence of hyperpolypharmacy (85%), frailty (80%) and neurocognitive disorders (30%). Acceptability was high (97%), along with CGA accessibility (100%); however, MDT accessibility varied (53-90%). Adherence to MDT intervention was low; with only 26% of patients completing physiotherapy sessions and only 29% adhering to dietary advice. Accurate recall was a significant factor contributing to poor adherence. Comprehensive geriatric assessment was demonstrated to be a broad and flexible intervention. CGA with MDT input is an acceptable and accessible intervention to be utilised as part of improved preoperative care for the older person undergoing elective orthopaedic surgery. Further consideration around methods to increase adherence in this patient group should be explored. Future research should focus on refining the intervention, and quantifying impact on patient outcomes.

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.

Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients

BackgroundTrauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds (“standard” CP; sCP), VTE rates...

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.

COVID-19 INFECTION RATE IN THE PERIOPERATIVE PERIOD FOR PATIENTS UNDERGOING ELECTIVE ORTHOPAEDIC SURGERY

COVID-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. The initial response to the pandemic included the cessation of routine services including elective orthopaedic surgery. There was apprehension among both surgeons and patients about restarting elective surgical services. The high mortality rate in perioperative patients who contract COVID-19 was of particular concern. The aim of this study was to identify the perioperative viral transmission rate in orthopaedic patients at our institution following the restart of elective surgery between August 2020 and November 2020 after the first wave of Covid in the UK.All patients who had their elective Orthopaedic surgeries at our institution from 1st August 2020 to 30th November 2020 were checked whether they were Covid positive or experienced COVID symptoms within 2 weeks after the operation. All patients were advised a 14-day period of comprehensive social distancing, 3 days of self-isolation and had a negative COVID-19 test within 72 hours of surgery and underwent surgery at a COVID free site. The patients were contacted and the hospital database was searched to identify those patients who were Covid positive or had Covid symptoms after the surgery. Baseline patient characteristics were recorded including age, gender, procedure, the subspeciality and admission type. Patients who underwent emergency procedures and trauma operations were excluded.Out of the 499 patients, 315 were contacted over telephone and hospital database was searched for the rest of the patients. We found that none of the patients were positive for COVID or had symptoms of COVID within two weeks of surgery. 5 patients were COVID positive with symptoms few months after the procedure and all of them recovered. There were 144 inpatient admissions and 353 day cases.The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. Findings of our study confirms that COVID-free elective pathway is an efficient process, and this could be implemented in future elective Orthopaedic surgeries during COVID times. Elective surgery can be safely resumed using dedicated pathways and procedures -Surgeons, hospital staff and patients should remain vigilant.

The effect of intravenous remifentanil and fentanyl postoperative delirium incidence in patients receiving elective orthopedic surgeries

Background: The use of certain opioids associated differently with the incidence of postoperative delirium (POD). Remifentanil and fentanyl are short-acting opioids widely used in surgery; however, studies assessing their relationship with POD incidence are still limited. This study aimed to determine the association of remifentanil and fentanyl uses with the incidence of POD in elective orthopedic surgery patients. Methods: A cross-sectional study was conducted in Surgical Unit at Dr Soetomo General Academic Hospital in Surabaya, Indonesia from August to September 2022. Patients who underwent elective orthopedic surgery and used remifentanil (n=16) and fentanyl (n=14) as postoperative analgesia were enrolled in the study. Delirium was assessed using Confusion Assessment Method-ICU tool (CAM-ICU). The associations of remifentanil and fentanyl use as well as patients’ characteristics with POD incidence were assessed statistically. Results: Our data found that there was no significant difference between the incidence of POD with the use of remifentanil (p=0.125) in orthopedic surgery patients. The total doses of fentanyl and morphine equivalent (of remifentanil or fentanyl) were associated significantly with the POD incidence (p=0.010 and p=0.002, respectively). Other factors associated with POD incidence were the use of bone cement during the surgery (p=0.034), duration of surgery (p&lt;0.001), and bleeding volume during the surgery (p=0.024). Conclusions: Our study showed high dose of fentanyl, use of bone cement, longer duration of surgery, and high bleeding volume have greater risk of developing POD in orthopedic surgery patients.

Benefit of medication reviews by renal pharmacists in the setting of a computerized physician order entry system with clinical decision support.

A 'renal pharmacist consultant service' (RPCS) reviewing patients' charts with renal impairment (RI) for drug-related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)-system with a clinical decision support (CDS)-system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE-CDS-system already in use and its effectiveness on prescription changes to ensure in-hospital patient safety. Over a period of 3 months (02-04/2021), elective orthopaedic and trauma patients with eGFRabsolute /CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE-system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFRnon-indexed /CrCl <60 ml/min and a pharmacist-led medication review was performed for all medication presented in the CPOE-system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1-3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by 'dosage too high' (n=55, 52.9%), 'dosage regime wrong' (n=13, 12.5%), and 'contraindication' (n=9, 8.7%). Acceptance rate of recommendations was 74.0% (n=77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. In the setting of prescribing in a CPOE-CDS-system, that provides physicians with advice for drug or dose adaption, the pharmacist-led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

Additional saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation: a prospective cohort study

BackgroundThe first aim of this study was to investigate the impact of providing an additional four hours of Saturday occupational therapy to patients receiving Saturday physiotherapy in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday occupational therapy service in addition to physiotherapy resulted in a net cost savings for the rehabilitation facility.MethodsA prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit from 2015–2017. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs.ResultsA total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (receiving Saturday occupational therapy and physiotherapy) had 192 participants and the historical control group (receiving Saturday physiotherapy only) had 174 participants. On admission, intervention group participants had higher cognitive (p < 0.01) and total (p < 0.01) Functional Independence Measure scores. Participation in weekend therapy by the intervention group was 11% higher, attending more sessions (p < 0.01) for a greater length of time (p < 0.01) compared to the historical control group.After controlling for differences in admission Functional Independence Measure scores, rehabilitation length of stay was estimated to be reduced by 1.39 (p = 0.08) days. The economic evaluation identified potential cost savings of AUD1,536 per patient. The largest potential savings were attributed to neurological patients AUD4,854. Traumatic and elective orthopaedic patients realised potential patient related cost savings per admission of AUD2,668 and AUD2,180, respectively.ConclusionsImplementation of four hours of Saturday occupational therapy in addition to physiotherapy results in a more efficient service, enabling a greater amount of therapy to be provided on a Saturday over a shorter length of stay. Provision of multidisciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital.

Is it time to resume elective knee arthroplasty surgery? A multidisciplinary experience in a Sardinian center during the SARS-CoV-2 pandemic.

Starting in January 2020, the SARS-CoV-2 pandemic caused changes in the nation's health systems. The hospital's reorganization led to a near-total stop of non-urgent, elective surgeries across all specialties, including hip and knee arthroplasty. However, in May 2020, a gradual elective surgery restarting was possible. Considering the risk of COVID-19 infections, the European Knee Associates suggest the need to implement specific protocols for a safe return to orthopaedic elective surgery. A retrospective analysis regarding all patients who underwent primary knee arthroplasty (TKA) between March 1st and October 1st, 2020 using an institutional database was performed. The study time was divided into 2 periods: Pandemic (from March 2020 to May 2020), Post Pandemic (from June 2020 to October 2020). A specific protocol was designed to safeguard the health of patients and healthcare workers during the SARS-CoV-2 pandemic. A total of 147 patients underwent total knee replacement surgery in the analyzed period. The mean surgical time was 77.6 (+/-18.9). The intraoperative mean blood loss was 54 (+/-28) ml. The mean hospital stay was 3-4 days. Among the treated patients no case of COVID-19 infection was observed. The use of our protocol, developed ad hoc for the management of elective orthopedic patients, allowed the restart of elective orthopedic surgery in a safe and reproducible way with an average increase of 374% on surgical activity between the pandemic and post-pandemic periods without record cases of contagion among the treated patients.

Preoperative Optimization Enables Identification of Undiagnosed Diabetics in Elective Orthopedic Surgery

We set out to assess the prevalence of undiagnosed diabetes among elective orthopedic surgery patients using a preoperative hemoglobin A1c (HbA1c) test. We also aimed to evaluate short term clinical outcomes and any possible surgical delays due to poor glycemic control.

Risk management in orthopedic surgery : Stratification and adjustment of patient-individual risk factors

Preoperative identification of patients at risk of postoperative complications enables better patient education and surgical planning for the orthopedic surgeon. In addition to demographic and intervention-specific factors, avariety of instruments are available for individual risk assessment. The concept of frailty seems to be promising to identify patients at risk. Modifiable risk factors such as malnutrition, anemia, obesity, smoking, and insufficiently controlled diabetes mellitus are common in elective orthopedic patients. With the use of screening protocols, modifiable risk factors can be identified and optimized preoperatively in order to reduce the individual risk of complications. Recommendations regarding preoperative risk stratification and modification prior to elective hip replacement have meanwhile been incorporated in national guidelines.

Resuming elective orthopaedic services during the COVID-19 pandemic : our experience.

AimsThe aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery.MethodsThis was a prospective study of all elective orthopaedic patients within an elective unit running a green pathway at a COVID-19 light site. Rates of preoperative and 30-day postoperative COVID-19 symptoms or infection were examined for a period of 40 weeks. The unit resumed elective orthopaedic services on 29 June 2020 at a reduced capacity for a limited number of day-case procedures with strict patient selection criteria, increasing to full service on 29 August 2020 with no patient selection criteria.ResultsA total of 2,373 cases were planned in the 40-week study period. Surgery was cancelled in 59 cases, six (10.2%) of which were due to having a positive preoperative COVID-19 screening test result. Of the remaining 2,314, 996 (43%) were male and 1,318 (57%) were female. The median age was 67 years (interquartile range 59.2 to 74.6). The median American Society of Anesthesiologists grade was 2. Hip and knee arthroplasties accounted for the majority of the operations (76%). Six patients tested positive for COVID-19 preoperatively (0.25%) and 39 patients were tested for COVID-19 within 30 days after discharge, with only five patients testing positive (0.22%).ConclusionThrough strict application of a COVID-19 green pathway, elective orthopaedic surgery could be safely delivered to a large number of patients with no selection criteria.Cite this article: Bone Jt Open 2021;2(11):951–957.

Cost-utility analysis of single nucleotide polymorphism panel-based machine learning algorithm to predict risk of opioid use disorder.

Aim: To conduct a cost-utility analysis of a novel genetic diagnostic test (OUDTEST) for risk of developing opioid use disorder for elective orthopedic surgery patients. Materials & Methods: A simulation model assessed cost-effectiveness and quality-adjusted life-years (QALYs) for OUDTEST from private insurer and self-insured employer perspectives over a 5-year time horizon for a hypothetical patient population. Results: OUDTEST was found to cost less and increase QALYs, over a 5-year period for private insurance (savingsUS$2510; QALYs 0.02) and self-insured employers (-US$2682; QALYs 0.02). OUDTEST was a dominant strategy in 71.1% (private insurance) and 72.7% (self-insured employer) of model iterations. Sensitivity analyses revealed robust results except for physician compliance. Conclusion: OUDTEST was expected to be a cost-effective solution for personalizing postsurgical pain management in orthopedic patients.

The obesity paradox and orthopedic surgery.

The Obesity Paradox describes the counterintuitive finding that although obesity contributes to the development of chronic conditions such as chronic kidney disease and cardiovascular disease, obesity seems to improve mortality in patients with these diseases. This paradox has also been sited in the critical care literature in regard to acute kidney injury, obesity and mortality. This study's objective is to examine the impact of obesity and post-surgical acute kidney injury on hospital length of stay and 2-year mortality after orthopedic surgery.We reviewed the electronic medical records of all adult elective orthopedic surgery patients over 2 years in a large academic hospital. The 1783 patients who met inclusion criteria were divided into obese (body mass index, BMI ≥ 30, n = 1123) and non-obese groups (BMI <30, n = 660). Demographics, medications, comorbidities, and perioperative variables were included in multivariable logistic regression analyses with acute kidney injury, length of hospital stay, and two-year mortality as primary outcomes. Outcomes were analyzed for the entire group, the obese cohort and the non-obese cohort.Acute kidney injury developed in 5% of the post-surgical orthopedic patients. Obesity increased the likelihood of developing acute kidney injury post orthopedic surgery (odds ratio [OR] = 1.82; 95% Confidence interval [CI] 1.05–3.15, P = .034). Acute kidney injury increased length of stay by 1.3 days and increased the odds of two-year mortality (OR = 2.08; 95% CI 1.03–4.22, P = .041). However, obese patients had a decreased likelihood of two-year mortality (OR = 0.53; 95% CI 0.33–0.84, P = .009).In adult orthopedic surgery patients, obesity increased the risk of acute kidney injury. Patients who developed an acute kidney injury had longer hospital stays and higher two-year mortality. Paradoxically, obesity decreased two-year mortality.

Challenges and responses of elective orthopaedic surgery during the second wave of COVID-19

BackgroundElective orthopaedic surgery has been severely curtailed because of coronavirus disease, 2019. There is scant scientific evidence to guide surgeons in assessing the protocols that must be implemented before resuming elective orthopaedic surgery safely after the second wave of the coronavirus disease, 2019. MethodsA retrospective review of elective orthopaedic surgeries performed between May 15, 2020, and November 20, 2020, was conducted. A screening questionnaire was used, and reverse transcription-polymerase chain reaction and severe acute respiratory syndrome coronavirus-2 immunoglobulin G and IgM antibodies testing were assessed in all admitted patients. Screening and testing data for coronavirus disease was reviewed for all patients. ResultsOf 592 patients tested for severe acute respiratory syndrome coronavirus-2 during the study period, 21 (3.5%) tested positive. There were 2 patients (0.3%) with positive reverse transcription-polymerase chain reaction tests, 3 (0.5%) with positive IgG and IgM antibodies, 13 (2.2%) with positive IgG antibodies, and 10 (1.7%) with positive IgM antibodies. Among these 21 patients, 20 (95.2%) were asymptomatic. ConclusionsOur findings suggest that most elective orthopaedic surgery patients with severe acute respiratory syndrome coronavirus-2 are asymptomatic. In the second wave of coronavirus disease, 2019, universal testing of all patients should be strongly considered as an important measure to prevent clusters of in-hospital transmission of the disease.

Do we achieve the Montgomery standard for consent in orthopaedic surgery?

The Montgomery v Lanarkshire Health Board (2015) case set a precedent that has driven the modernisation of consenting practice. Failure to demonstrate informed consent is a common source of litigation. This quality improvement project aimed to provide pragmatic guidance for surgeons on consent and to improve the patient experience during decision making. Elective orthopaedic patients were assessed and the quality of documented consent was recorded. Data were collected over two discrete cycles, with cycle 1 used as a baseline in practice. The following criteria were reviewed: grade of consenting clinician, alternative treatment options, description of specific risks, place and timing of consent and whether the patient received written information or a copied clinic letter. Cycle 1 results were presented to clinicians; a teaching session was provided for clinicians on the standard of consent expected and implementation of a change in practice was established with a re-audit in cycle 2. There were 111 patients included in cycle 1, and 96 patients in cycle 2. Consent was undertaken mostly by consultants (54%). Specific patient risks were documented in 50% of patients in cycle 1 and 60% in cycle 2. Risks associated with a specific procedure were documented in 42% in cycle 1 and 76% in cycle 2, alternative options in 48% (cycle 1) and 66% (cycle 2). A total of 14% of patients in cycle 1 and 8% in cycle 2 had documented written information provision. Copied letters to patients was only seen in 12% of all cycles. Documentation from dedicated consenting clinics outperformed standard clinics. Highlighting poor documentation habits and refining departmental education can lead to improvements in practice. The use of consenting clinics should be considered and clinicians should individually reflect on how to address their own shortcomings. Other units should strongly consider a similar audit. This article provides stepwise advice to improve consent and specifics from which to audit.

The efficacy of remote virtual care in comparison to traditional clinical visits for elective orthopaedic patients: A meta-analysis of prospective randomised controlled trials

IntroductionThe Orthopaedic Trauma Association has recommended limitation of in-person encounters to absolute necessity. One method of ensuring standard patient care within these guidelines is through the implementation of telemedicine. AimsTo evaluate the efficacy of telemedicine for elective orthopaedic patients in the recovery and/or rehabilitation period. MethodsA systematic review and meta-analysis of articles in Medline/PubMed and The Cochrane Library databases was performed according to the PRISMA guidelines for prospective randomised controlled trials to compare clinical and symptomatic measures for elective patients managed routinely with remote care compared to those managed with standard in-clinic management. To be included for meta-analysis, parameters must be evaluated in ≥3 studies. ResultsEleven studies were included in the meta-analyses. Both telemedicine and control cohorts were comparable for patient satisfaction (RR, 0.98; 95% CI, 0.90–1.07; I2 = 0%; p = 0.52) and patient retention analysis (RR, 1.25; 95% CI, 0.51–3.06; p = 0.54; I2 = 0%). Similarly, there was no statistical difference appreciated between cohorts for overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (p = 0.30), Timed Up and Go Test (p = 0.40), and Stair Test (p = 0.18). Significant difference did exist for visual analogue scale (VAS) scores (p = 0.02) in favour of in-clinic management. ConclusionTelemedicine will serve an integral aspect of healthcare delivery throughout the current COVID-19 pandemic and beyond in an effort to deliver safe, efficient and time-sensitive care to the orthopaedic patient population. The results of our meta-analyses indicate that virtual consultations are as effective as traditional in-person consultations for the care of elective orthopaedic patients in the recovery and rehabilitation period. However, further studies are needed to evaluate for initial consultations and certain sub-specialties of orthopaedics.