Hip Surgery Patients Research Articles

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial

BackgroundThere are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population.MethodsA total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat.ResultsExcept for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75–1.31) and 1.06 (0.80–1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up.ConclusionsThere was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

Preoperative SSRI use increases perioperative transfusion need in patients undergoing surgical procedures on the hip joint.

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for psychiatric conditions. Previous studies have shown that SSRIs can increase bleeding risk by affecting platelet aggregation. However, their impact on perioperative outcomes in hip surgery remains uncertain. This case-control study examines the link between preoperative SSRI use and perioperative transfusion requirements in hip surgery patients. Data from the M161Ortho dataset of Pearl Diver patient records database were utilized. Patients who underwent hip joint surgery between 2010 and 2022 and had documented preoperative SSRI use within one month prior to surgery were included. Patients with coagulopathy disorders or coagulopathy medication use were excluded. Perioperative transfusion need was defined as receiving red blood cell or whole blood transfusions on the same date or within 10 days following the surgery. A total of 75,374 patients with preoperative SSRI use were matched with an equal number of non-SSRI users. Preoperative SSRI use was associated with an increased risk of requiring perioperative transfusion (5.7% vs. 5.1%, P < 0.001). Subgroup analysis demonstrated increased transfusion risk in patients undergoing pinning (2.6% vs. 1.8%, P = 0.02), open reduction with internal fixation (ORIF) (8.9% vs. 8.2%, P = 0.007), and total hip arthroplasty (THA) (3.8% vs. 3.4%, P < 0.001), but no significant difference was observed in patients undergoing hemiarthroplasty. Clinicians should be aware of the potential risk of increased perioperative transfusion requirements in hip surgery patients using SSRIs, especially during pinning, ORIF, and THA procedures. It is essential to consider this when managing patients on SSRIs before hip surgery.

Effect of bupivacaine concentration on ultrasound-guided pericapsular group nerve block efficacy in hip surgery patients: comparative, randomized, double-blinded clinical trial.

The pericapsular nerve group (PENG) block offers effective postoperative pain relief following hip fracture surgery. This research investigated three doses of bupivacaine, all administered in the same total volume, for performing ultrasound-guided PENG blocks during hip fracture procedures. This randomized, double-blinded clinical trial was conducted on 135 patients aged between 18 and 70 years of both sexes who underwent hip fracture surgeries. Participants were randomized into three groups (n = 45). Ultrasound-guided PENG block was applied, the groups received 20mL of local anesthetics. The first group received 0.5% bupivacaine, the second group received 0.375% bupivacaine, and the third group received 0.25% bupivacaine. The following parameters were recorded: onset of sensory block, resting NRS after passively raising the limb by 15° half an hour post-procedure, quality of recovery score (QoR-15) at 24h postoperative. The 0.25% bupivacaine group exhibited a longer sensory block onset than the other groups (p ≤ .05). Significant differences were demonstrated between the groups regarding the time to 1st analgesia (p = .033) and total morphine consumption (p = .025). NRS at baseline and T30 post-block did not show significant differences between the studied groups. No significant differences were detected postoperatively in rest and dynamic NRS (p ≤ .05). Patient satisfaction, QoR-15 score, and ease of spinal positioning did not differ between the groups. Compared to 0.25% bupivacaine, PENG block with 0.5% and 0.375% bupivacaine provided a rapid onset sensory block, delayed first analgesic requirements, and reduced total morphine consumption after hip surgeries. The trial was registered at the clinicaltrials.gov with study number (Trial ID: NCT05788458).

Patient participation in orthopaedic care—a survey on hip surgery patients’ preferences for and experiences of engagement in their health and healthcare

IntroductionQuality in health services is increasingly associated with enabling patients to participate in their own health and healthcare by recognising their resources and needs. Despite a growing recognition as to whether such participation is enabled, little is known regarding opportunities for preference-based patient participation in orthopaedic care. AimsTo investigate preference-based participation for patients in orthopaedic care due to hip surgery. MethodsPatients across 17 Swedish orthopaedic units who had had hip surgery, due to hip fracture or osteoarthritis, January–April 2021 were invited to complete the validated 4Ps questionnaire. Of 1514 patients, 458 patients returned the questionnaire with reports on their preferences for and experiences of participation. Each of the 4Ps’ 12 items were analysed separately using descriptive and comparative statistics. ResultsA complete match in preferences for, and experiences of, participation was achieved with variation between items for 41%–50% of the patients; if almost matches were included, this occurred for 57%–77% of the patients. Less participation than preferred was most common in terms of having had reciprocal communication, opportunities for partaking in planning, and in learning how to manage symptoms/issues. Hip fracture surgery was significantly associated with experiencing lower levels of participation than preferred. ConclusionThough standardised care promotes efficient hip surgery care, our study suggests a need for more person-centred opportunities to engage. A discrepancy was noted between patients’ resources and preparation for their participation in and beyond the hip surgery process, particularly for self-care activities, calling for better use of nursing resources. IdNCT04700969 with the U.S National Institutes of Health Clinical Registry.

Adherence to evidence-based guidelines for prevention of urinary retention in hip surgery patients: a multicentre observational study.

Urinary retention is a healthcare complication putting patients at risk of unnecessary suffering and harm. Orthopaedic patients are known to face an increased such risk, calling for evidence-based preoperative assessment and corresponding measures to prevent bladder problems. The aim of this study was to evaluate healthcare professionals' adherence to risk assessment guidelines for urinary retention in hip surgery patients. This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources: (I) Medical records for 1382 hip surgery patients across 17 hospitals in Sweden were reviewed for preoperative risk assessments for urinary retention and voiding-related variables at discharge; (II) The patients completed a survey regarding postoperative lower urinary tract symptoms, and; (III) data were extracted from a national quality registry regarding type of surgery, preoperative physical status, and perioperative urinary complications. Group differences were analysed with Chi-square/Fisher's exact test, t-test, Wilcoxon rank-sum test, or Mann-Whitney U-test. Logistic regression was used to analyse variables associated with completed risk assessments for urinary retention. Of all study participants, 23.4% (n=323) had a preoperative documented risk assessment of urinary retention. Whether a risk assessment was performed was significantly associated with acute surgery [odds ratio (OR) 3.56, 95% confidence interval (CI) 2.48-5.12] and undergoing surgery at an academic hospital (OR 4.59, 95% CI 2.68-7.85). Acute patients were more often affected by urinary retention and had bladder issues and/or an indwelling catheter at discharge. More than every tenth patient (11. 9%, n=53) completing the survey experienced intensified bladder problems after their hip surgery. The study shows a lack of adherence to risk assessment for urinary retention according to evidence-based guidelines, which negatively affects quality of care and patient safety.

Effectiveness of Taohong Siwu decoction in the prevention of deep vein thrombosis in hip surgery patients: A systematic review and meta-analysis of randomized controlled trials.

This systematic review and meta-analysis aimed to evaluate the effects of Taohong Siwu Decoction (THSWD) combined with low molecular weight heparin (LMWH), as well as THSWD alone, on the incidence of Deep vein thrombosis (DVT), D-dimer levels, prothrombin time (PT), activated partial thromboplastin time (APTT), visual analogue scale (VAS) pain score, and calf swelling in patients undergoing hip fracture or replacement surgery, compared to LMWH. According to the predefined inclusion criteria, we conducted a comprehensive search for randomized controlled trials (RCTs) examining the efficacy of THSWD combined with LMWH or THSWD compared to LMWH in patients with hip fractures or undergoing replacement surgery. The search was performed across multiple databases including China National Knowledge Internet, WanFang, Sinomed, Duxiu, PubMed, Embase, Google Scholar, Cochrane, and Web of Science from their inception until December 2023. Additionally, relevant literature references were retrieved and hand searching of pertinent journals was conducted. The methodological quality assessment of the included trials was carried out following the guidelines outlined in the Cochrane Handbook. Review Manager 5.4 was applied in analyzing and synthesizing. A total of 18 RCTs with 1353 patients were included. The results of meta-analysis showed that compared with the control group, the combined group had a better effect on the incidence of DVT [RR = 0.32, 95% CI(0.17, 0.58; P = .0002], D-dimer [SMD = -5.88, 95% CI(-7.66, -4.11); P < .00001], VAS [MD = -1.16, 95% CI(-1.81, -0.50); P = .0005], Calf circumference difference [MD = -0.56, 95% CI(-1.05, -0.08); P = .02]. There was no significant difference in PT and APTT between the combined group and the control group. Meta-analysis results show that the D-dimer, incidence of DVT, PT, and APTT did not significantly differ between the THSWD and the LMWH groups. This meta-analysis shows that compared with LMWH, THSWD combined with LMWH has a better efficacy in the treatment of DVT after hip surgery, without a significant increase in the incidence of adverse events. Additionally, the combined therapy can also reduce D-dimer, VAS, and swelling. However, due to the limitations of the included studies (such as small sample size and low-quality evidence), the results need to be further verified in more rigorous multicenter clinical trials with a large sample size.

Timely Surgical Intervention Leads to Better Sustained Coverage after Reconstructive Hip Surgery in Patients with Cerebral Palsy.

In up to 45-90% of non-ambulatory patients with cerebral palsy (CP), progressive hip migration can be observed. The goal of this study was to determine whether the implementation of a national hip surveillance guideline affected the outcome of hip reconstructions. We reviewed 48 primary hip reconstructions at a median follow-up of 4.4 years. Surgical outcome was evaluated based on complication rates and radiographic evaluation postoperatively and at follow-up. Radiographic measurements included the migration percentage (MP), head-shaft angle and acetabular index. The impact of preoperative MP, postoperative MP, tone management, Gross Motor Function Classification System (GMFCS) classification and age on MP at follow-up were examined using a mixed model analysis. A decrease in preoperative MP was noted, from a median of 75.0% (2014) to 39.0% (2020). Lower preoperative MP showed a significant correlation to lower MP postoperatively (p = 0.012). Postoperative MP was a significant independent predictor of a lower MP at follow-up (p = 0.002). This study shows an improvement in the timing of hip reconstruction in patients with CP after implementation of the hip surveillance guideline. A reduction in preoperative MP resulted in improved postoperative outcomes. A lower postoperative MP was the most important predictor for sustained containment of the hip.

Risk factors for postoperative delirium in orthopaedic hip surgery patients: a database review

BackgroundPostoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture.MethodsThe 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed.ResultsOverall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p < 0.001), had a lower BMI (19.5 vs. 24.8, p < 0.001), were more likely to have a history of dementia (54.6% vs. 13.6%, p < 0.001), were less likely to have an independent functional status (p < 0.001) or live alone (p < 0.001), and were more likely to have sustained a recent fall (p < 0.001). Delirium patients were more likely to be hyponatremic or hypernatremic (p = 0.002), anemic (p < 0.001), and severely dehydrated (p < 0.001), among other lab abnormalities. Delirium patients were also more likely to experience additional postoperative complications, including pneumonia, pulmonary embolism, urinary tract infection, stroke, cardiac arrest, sepsis, and unplanned reoperation and readmission after discharge (all p < 0.05).ConclusionsIn this study, factors associated with postoperative delirium in patients undergoing hemiarthroplasty and THA were identified, including older age, lower BMI, certain medical conditions, decreased functional status, certain lab abnormalities, and postoperative complications. These findings can be used by clinicians to better inform care and to determine when orthopaedic joint replacement patients may be at an increased risk for postoperative delirium.

Transcutaneous Electrical Nerve Stimulation Integrated into Pants for the Relief of Postoperative Pain in Hip Surgery Patients: A Randomized Trial.

The effect of transcutaneous electrical nerve stimulation (TENS) on pain and impression of change was assessed during a 2.5-hour intervention on the first postoperative days following hip surgery in a randomized, single-blinded, placebo-controlled trial involving 30 patients. Mixed-frequency TENS (2 Hz/80 Hz) was administered using specially designed pants integrating modular textile electrodes to facilitate stimulation both at rest and during activity. The treatment outcome was assessed by self-reported pain Numerical Rating Scale (NRS) and Patient Global Impression of Change (PGIC) scores at four time points. The ability to perform a 3-meter walk test and the use of analgesics were also evaluated. Group comparison and repeated-measure analysis were carried out using nonparametric statistics. The active TENS group exhibited significantly higher PGIC scores after 30 minutes, which persisted throughout the intervention (all p ≤ 0.001). A reduction in NRS appeared after one hour of active TENS, persisting throughout the intervention (all p ≤ 0.05). The median group differences in pain ratings were greater than the minimum clinically important difference, and the analysis of pain trajectories confirmed clinical significance at the individual level. Moreover, patients in the active TENS group were more likely able to perform a 3-meter walk test by the end of the intervention (p = 0.04). Analysis of the opioid-sparing effect of TENS was inconclusive (p = 0.066). No postoperative surgical complications or TENS-related side effects were observed during the study. Mixed-frequency TENS integrated in pants could potentially be an interesting addition to the arsenal of treatments for multimodal analgesia following hip surgery. This trial is registered with NCT05678101.

Quantifying Physical Resilience after Knee or Hip Surgery in Older Australian Women Based on Long-Term Physical Functioning Trajectories.

To improve outcomes after knee or hip surgery, better insight is needed in long-term recovery patterns in the context of ageing-related decline. We examined long-term trajectories of physical functioning (PF) in older women with and without hip and knee surgery and described profiles of cases with higher and lower resilience after surgery. This observational study used data from 10,434 women (73-79 years) who completed survey 2 of the Australian Longitudinal Study on Women's Health. Data were used from surveys 2 (1999) to 6 (2011). Covariable-adjusted linear mixed models were run to examine the surgery-by-time (-12 to +12 years) interaction in association with PF (SF-36 subscale). The differences between observed and expected PF were calculated, with positive/negative values reflecting higher/lower resilience, respectively. Women with hip surgery (n = 982) had lower PF than those without surgery (n = 8,117) (p &lt; 0.001). Among hip surgery patients, the decline was more rapid pre-surgery than post-surgery (Δslope = -0.7, p &lt; 0.001). Women with knee surgery (n = 1,144) had lower PF than those without surgery (n = 7,971), but with a slower rate of decline (p = 0.01). Among knee surgery patients, the rate of decline was similar pre- and post-surgery (Δslope = -0.3, p = 0.25). Both in hip and knee patients, women with higher resilience had fewer comorbidities and symptoms and were more often physically active and independent in daily activities than those with lower resilience (all p &lt; 0.05). Compared with women without surgery, PF was lower and declined more rapidly around the time of hip surgery, but not for knee surgery. Women with better long-term recovery after surgery had fewer health problems and were more independent around the time of surgery.

PHYSICAL FUNCTIONING 12 YEARS BEFORE AND AFTER KNEE OR HIP SURGERY IN OLDER WOMEN

Abstract Understanding long-term recovery patterns in the context of ageing-related decline may improve knee or hip surgery outcomes. We examined the impact of hip and knee surgery on long-term trajectories of physical functioning (PF) in older women, and profiled women with higher and lower resilience to surgery. Resilience, defined as bouncing back (PF) after a stressor (hip or knee surgery), was quantified using the expected recovery differential method. Data were from 10,434 women (73-79 yrs) in the Australian Longitudinal Study on Women’s Health who completed surveys 2-6 (1999-2011). Adjusted linear mixed models were run to examine the surgery-by-time (-12 to +12 yrs) interaction in association with PF (SF-36 subscale). The difference between observed and expected PF were calculated, with positive/negative values reflecting higher/lower resilience, respectively. PF trajectories differed between women with (n=982) and without (n=8117) hip surgery (p&amp;lt;0.001). Among hip surgery patients, the decline was more rapid pre-surgery than post-surgery (b=-0.7, p&amp;lt;0.001). Women with knee surgery (n=1144) had lower PF than those without surgery (n=7971), but with a slower rate of decline (p=0.01). Among knee surgery patients, the rate of decline was similar pre- and post-surgery (b=-0.3, p=0.25). Both in hip and knee patients, women with higher resilience had fewer comorbidities and symptoms, and were more often physically active and independent in daily activities than those with lower resilience (p&amp;lt;0.05). In conclusion, women with and without hip or knee surgery have different trajectories of PF. Women who function better than expected after surgery, tend to have fewer health problems.

PREOPERATIVE ANXIETY STATUS OF PATIENTS WITH HIP AND KNEE REPLACEMENT SURGERY

Objectives: This study was conducted to estimate the prevalence of preoperative anxiety status and find out some related factors in hip and knee replacement patients at the Department of Orthopedic Surgery and Sports Medicine, Hanoi Medical University Hospital. Subjects and Methods: A cross-sectional study recruited 102 patients scheduled for hip and knee replacement surgery. The research was conducted from June to September 2022. Preoperative anxiety status was measured by the Hospital Anxiety and Depression Scale (HADS). Results: The population ages varied from 22 to 92 years (mean age=62.11 ± 15.35 years). Nearly half of patients (48%) experienced preoperative anxiety ranging from mild to severe, with a mean HADS score was 7.21±3.13, and 32% of patients had mild anxiety. Surgical types and gender associated with preoperative anxiety status. The proportion of patients who reported being afraid of intra- and/ or postoperative complications, postoperative disabilities, and the pain was 80.4%, 65.7%, and 58.8%, respectively. Conclusion: The proportion of hip and knee replacement surgery patients who experienced preoperative anxiety was high. Surgical types and gender were significantly associated with the preoperative anxiety status of hip and knee replacement surgery patients (p&lt;0.05).

Experiences with and perception of patient-reported outcome measurement in patients undergoing knee and hip replacement in Germany.

Patient-reported outcome measures-PROMs-have been developed to provide an assessment of patients' physical function, symptoms, and health-related quality of life. With patient-centered care becoming increasingly important, several national strategies have been initiated for PROM measurement. However, Germany is only at the beginning of this process. The objective of this study is to assess patients' experience with and perception of completing PROMs in patients undergoing knee and hip replacement in Germany. This study used survey data from patients undergoing hip or knee replacement surgery in a hospital in Germany. Before surgery, patients completed a PROMssurvey. After at least 6 months, patients were re-contacted to fill in a questionnaire about their experiences with and perception of thePROMs data collection. Most patients either agreed or totally agreed that the time to fill in the questionnaire was appropriate (89%), that the purpose of the PROMs collection was clear (85%), that the questionnaire's content applied to their appointment (73%), and that this systematic assessment was beneficial (81%). The corresponding proportions were 54% for feeling productive while waiting and 50% for feeling that the information in the questionnaire affected the patient-doctor interaction positively. Only few significant associations were found between patient characteristics and the favorability of patients' ratings. There were no significant differences between hip and knee replacement surgery patients regarding the favorability rating on any survey question. The results of this study suggest that PROMs collection in the context of hip and knee replacement surgery is practicable and partly also perceived beneficial by patients. Orthopedic procedures could serve as a starting point for broader use and routine PROMs collection in Germany.

Morbidity and mortality in hip surgery patients due to fracture during the COVID-19 pandemic

BackgroundThe COVID-19 epidemic generated major changes in general surgical management protocols. The literature has reported high mortality rates for hip fracture surgery in patients with COVID-19. This study describes the morbidity and mortality in patients undergoing surgery due to hip fractures in 12 Colombian institutions between March and September 2020. MethodologyThis was a retrospective observational descriptive study. Medical records of 12 hospitals were reviewed. Consecutive patients who underwent hip fracture surgery from March 6 to September 6, 2020, were included. Data collected were sociodemographic profile, type of fracture, surgical treatment, complications, and early (1 month) or mid-term (1–6 months) mortality associated or not with COVID-19. ResultsFive hundred twenty patients with hip fractures requiring surgery in the 12 institutions were included. 364 (70%) were women; mean age was 77.7 years (SD: 13.8), mean BMI was 25.1, 91.73% of patients had at least one comorbidity, 60.38% were classified as ASA II and 25.77% as ASA III. There were 267 (51.34%) pertrochanteric fractures, 227 (43.65%) femoral neck fractures, and 26 (5.0%) subtrochanteric fractures. 274 (52.69%) patients were treated with osteosynthesis, 244 (46.92%) with arthroplasty, and 2 (0.38%) with girdlestone. Surgery was performed less than 24 h after the fracture for 115 (22.11%) patients, between 24 and 72 h for 208 (40.0%) patients, and more than 72 h for 197 (37.88%) patients. One hundred six patients in total suffered a medical or surgical complication throughout the different follow-up stages, amongst the most frequent were respiratory failure, coronary events, surgical site infection, cutting-out and peri‑implant fracture. 25 (4.8%) patients required attention in the Intensive Care Unit (ICU). 13 patients had COVID-19 throughout the follow-up period. 27 patients died due to any cause, and 3 of them had reported a positive COVID-19 test any time during follow-up period, of which one died during the first month, and two died between 1 and 6 months. Statistically significant associations were found between age older than 75 years old, ASA classification, ICU requirement, and death. Conclusion520 patients received surgical treatment for hip fracture during the first six months of the COVID-19 pandemic in 12 medical centers in Colombia. 21.10% suffered a complication during the early stage (30 days) and 4.77% during the midterm stage (1–6 months). 4.8% were admitted in the ICU during the early stage. All-cause death was 27 patients, early death was 11 (40.74%) and midterm death was 16 (59.25%). 13 patients were positive for COVID-19, 3 died, one (1/5=20%) on the first 30 days and the other two (2/8=25%) from month 1 to 6.

Ultrasound-Guided Peripheral Nerve Blocks for Hip Surgery: A Concise Perspective.

Ultrasound implementation for the facilitation of peripheral nerve blocks is well established. Ultrasound-guided lumbar plexus, femoral, fascia iliaca and supra-inguinal fascia iliaca compartment, pericapsular nerve group and quadratus lumborum nerve blocks have been employed for analgesia purposes in hip surgery. The combination of motor-sparing regional anesthesia strategies for optimal postoperative pain control with recovery protocols targeting to early and safe patients' mobilization constitute the current dogma of orthopedic surgery. Therefore, this editorial sets out to revisit the role of peripheral nerve blocks in postoperative pain management of hip surgery patients, under the prism of current orthopedic practice.

The effect of perioperative blood transfusion thresholds on patient outcomes in orthopaedic surgery: a literature review.

Blood transfusions are one of the most common interventions required perioperatively in orthopaedic patients. There exist two main schools of thought in relation to perioperative blood transfusion - transfusing at a haemoglobin level of 70 g/L or below (termed 'restrictive protocol' in the literature), versus transfusing at a haemoglobin threshold of 100 g/L (which the literature terms 'liberal'). Few reviews of the literature exist comparing the impact of different transfusion strategies on the postoperative outcomes of these orthopaedic patients. This review analyses the 11 currently available studies on transfusion protocols in orthopaedics and associated findings related to patient outcomes. The literature showed no clear consensus on whether one transfusion protocol is superior in the orthopaedic patient. There was strong evidence for reduced transfusion rates among groups receiving transfusion at <70 g/L, and hence a reduction in complication directly related to transfusions. Despite this, other measured patient outcomes, including length of stay, postoperative complication rate, and mortality rate, were unchanged between the groups. Some evidence exists that a Hb threshold of 100 g/L results in earlier postoperative ambulation in hip surgery patients. One study suggests using preoperative haemoglobin as a preoperative risk factor to aid in determining whether patients are more suited to one approach over the other. Further high-quality clinical trials in orthopaedic cohorts must become available to determine whether a haemoglobin threshold of 70 g/L can safely be adopted to reduce transfusion rates without adversely impacting patient outcomes.

Regional Anesthesia for Hip Surgery Patients: Review Article

Successful postoperative pain control is one of the keys on the patients’ recovery after surgery, especially in the hip fracture and hip reconstruction surgery. Currently, the concept on pain management with multimodal analgesia and regional anesthesia plays a key role for postoperative analgesia and has demonstrated the ability of enhancing postoperative recovery, reducing opioids consumption, and decreasing the time to mobilization. Nonetheless, the development of new regional analgesic techniques has evolved in the past four decades and can be intimidating to the general anesthesiologists. Therefore, the present article aimed to provide a concise review of the hip innervation and the current regional analgesic techniques as a practical guide for the perioperative pain management after hip surgery. Keywords: Total hip replacement; Hip fracture; Hip nerve innervation; Lumbar plexus block; Femoral nerve block; Fascia iliaca block; Pericapsular nerve group block; Quadratus lumborum block; Erector spinae plane block; Local infiltration analgesia; Postoperative analgesia

Preoperative Correction of Low Hemoglobin Levels Can Reduce 1-Year All-Cause Mortality in Osteoporotic Hip Fracture Patients: A Retrospective Observational Study.

PurposeOsteoporotic hip fracture surgery is associated with a risk of morbidity and mortality. Admission hemoglobin levels <10 g/dL have been documented as a strong predictor of mortality risk. This study aimed to investigate the mortality outcome between osteoporotic hip fracture patients who had preoperative hemoglobin levels raised to ≥10 g/dL and those with hemoglobin levels were <10 g/dL.Patients and MethodsThis 5-year retrospective observational study included 226 participants with osteoporotic hip fractures that required surgery and who had admission hemoglobin levels <10 g/dL. Patients were categorized into two groups: those with corrected preoperative hemoglobin ≥10 g/dL and those with either corrected or uncorrected preoperative hemoglobin <10 g/dL. Outcomes were analyzed using Cox proportional hazard regression adjusted for confounders. Results are presented as hazard ratio (HR) and 95% confidence interval (95% CI).ResultsAmong 226 the patients, the overall mortality rate was 17.25% (n=39/226) of the 226 patients, 93 (41.15%) had their hemoglobin levels raised to ≥10 g/dL by red blood cell transfusion. Multivariable analysis after adjustment for confounders showed a 50% lower incidence of mortality among patients with preoperative hemoglobin levels ≥10 g/dL than among those with hemoglobin levels <10 g/dL (HR 0.50, 95% CI (0.25–0.99), p=0.048).ConclusionIn osteoporotic hip fracture patients with admission hemoglobin <10g/dL, raising preoperative hemoglobin levels to ≥10 g/dL can significantly reduce the risk of mortality. Testing for and correction of low preoperative hemoglobin levels is of value in hip surgery patients.

Pre-operative nutrition assessments do not improve outcomes in cerebral palsy patients undergoing varus derotational osteotomy.

Pre-operative nutritional assessments have been used as a “cornerstone” to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as “non-ambulatory” (Gross Motor Function Classification System [GMFCS] IV–V), and 45 (29%) as “ambulatory” (GMFCS I–III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative.

Prediction of cytochromes P450 3A and 2C19 modulation by both inflammation and drug interactions using physiologically based pharmacokinetics.

Xenobiotics can interact with cytochromes P450 (CYPs), resulting in drug–drug interactions, but CYPs can also contribute to drug–disease interactions, especially in the case of inflammation, which downregulates CYP activities through pretranscriptional and posttranscriptional mechanisms. Interleukin‐6 (IL‐6), a key proinflammatory cytokine, is mainly responsible for this effect. The aim of our study was to develop a physiologically based pharmacokinetic (PBPK) model to foresee the impact of elevated IL‐6 levels in combination with drug interactions with esomeprazole on CYP3A and CYP2C19. Data from a cohort of elective hip surgery patients whose CYP3A and CYP2C19 activities were measured before and after surgery were used to validate the accurate prediction of the developed models. Successive steps were to fit models for IL‐6, esomeprazole, and omeprazole and its metabolite from the literature and to validate them. The models for midazolam and its metabolite were obtained from the literature. When appropriate, a correction factor was applied to convert drug concentrations from whole blood to plasma. Mean ratios between simulated and observed areas under the curve for omeprazole/5‐hydroxy omeprazole, esomeprazole, and IL‐6 were 1.53, 1.06, and 0.69, respectively, indicating an accurate prediction of the developed models. The impact of IL‐6 and esomeprazole on the exposure to CYP3A and CYP2C19 probe substrates and respective metabolites were correctly predicted. Indeed, the ratio between predicted and observed mean concentrations were <2 for all observations (ranging from 0.51 to 1.7). The impact of IL‐6 and esomeprazole on CYP3A and CYP2C19 activities after a hip surgery were correctly predicted with the developed PBPK models.