Major Orthopedic Surgery Research Articles

A Major Orthopaedic Surgery in a Hundred-year-old Patient During Pandemic of COVID 19: A Case Report

It has been undoubtedly assumed that COVID-19 imposes an immense economical and psychological trauma to all common people. It is also true that COVID-19 had been appeared like a “world war” for health care workers all over the world. However, either conservative or operative treatment were offered for all trauma patients even during that period. We report a 100 years old female patient with femoral shaft fracture who was treated with intramedullary interlocking nail with full precautions to prevent virus transmission during lock down period. The post and perioperative complications were uneventful, and she was walking comfortably after surgery. Keywords: COVID 19; Femoral fracture; Lock down; Pandemic

Rotational Thromboelastometry: Enhancing Hemostasis Monitoring in Anesthesia

Rotational thromboelastometry (ROTEM) is a viscoelastic point-of-care coagulation test that measures the dynamics of clot formation and lysis in whole blood samples. A cylindrical shaft that oscillates while passing through a tiny amount of blood is used in the procedure. Blood exerts increasing pressure on the shaft as it thickens into a clot. We can track the strength of the forming clot over time by measuring this resistance. ROTEM® can provide valuable information about the coagulation status of patients who are at risk of bleeding or thrombosis in various peri-operative settings, such as trauma, obstetrics, cardiac surgery, liver transplantation, and major orthopedic and vascular surgeries. In addition, it can aid in the diagnosis and treatment of peri-operative coagulopathy, reduce unneeded transfusions, and enhance patient outcomes.

Comparison of different intervention methods to reduce the incidence of venous thromboembolism: study protocol for a cluster-randomized, crossover trial

BackgroundVenous thromboembolism (VTE) remains a priority challenge among orthopedic trauma patients. It is crucial to further improve the prophylaxis against VTE in routine orthopedic treatment. This study aims to compare the efficacy of two low molecular weight heparin (LMWH) regimens and additional intermittent pneumatic compression in preventing VTE among orthopedic trauma patients.Methods and analysisThis is a cluster-randomized crossover clinical study conducted in four hospitals in Shanghai from December 2019 to December 2023. The unit of randomization is orthopedic wards, and each ward will define a cluster. All clusters will implement four diverse intervention measures and one control measure in a given random sequence. Perioperative orthopedic trauma patients aged ≥ 18 years with stable vital signs, Caprini score > 2, and no contraindication of anticoagulation or intermittent pneumatic compression (IPC) devices will be eligible. The sample size will be determined to be 2590, considering cluster effect, period effect, and interactions. We will generally use the intention-to-treat (ITT) at the subject level for each outcome. For the primary outcome of the study, the incidence of VTE will be presented as risk ratio and 95% CIs. Generalized estimating equation (GEE) will be deployed to compare differences and adjust cluster effect, period effect, and interaction among interventions and periods if applicable.DiscussionVTE is a complication that cannot be underestimated after major orthopedic surgery. Early identification, early assessment, and early prevention can significantly reduce the incidence of VTE. Most guidelines recommend both medical and physical prevention, and we hope to demonstrate how they would affect the incidence among perioperative orthopedic patients. We want to explore if there is a difference between the two types of LWMH with or without an IPC device to provide more evidence for future guidelines and prevent more patients from the threat of VTE.Ethics and disseminationThe study received approval from the IRB of the coordinating center and all participating hospitals. Findings will be disseminated through peer-reviewed publications and conference presentations.Trial registrationChiCTR1900027659. Registered on 17 November 2019

Hormonal Contraception and Menopausal Hormone Therapy: A Reference for Orthopaedic Surgeons

BACKGROUND: Exogenous estrogen is a double-edged sword in the realm of orthopaedic surgery, providing many musculoskeletal health benefits to menopausal women yet adding an additional risk of venous thromboembolism (VTE) in the perioperative setting for patients using certain forms of hormonal contraception and menopausal hormone therapy (MHT). The primary objective of this review is to summarize the known literature regarding the VTE risks of perioperative medications containing exogenous estrogen among orthopaedic patients. A secondary objective is to provide guidance to orthopaedic surgeons regarding perioperative management of commonly encountered forms of hormonal contraception and MHT. METHODS: A summative review of existing literature regarding VTE risk of various forms of hormonal contraception and MHT is provided, with emphasis on perioperative VTE risk surrounding major and minor orthopaedic surgery. RESULTS: Increased risk of VTE has been identified after arthroscopic knee procedures in patients utilizing oral contraceptive pills and after major lower extremity surgery in patients using MHT, yet there is not a clear standard of care as to how to manage these medications after surgery or how and when to adjust VTE prophylaxis. Regardless of the mode of delivery (pills, patches, vaginal rings), hormonal contraception with exogenous estrogen carries some associated VTE risk that can be compounded by surgery. Depo-Provera has also demonstrated increased risk. Forms of hormonal contraception without elevated VTE risk are progestin only pills and intrauterine devices (IUDs) as well as Nexplanon. MHT with systemic level doses of exogenous estrogen delivered orally has associated VTE risk. While systemic transdermal and transvaginal formulations of estrogen have not been shown to increase VTE risk in the non-surgical state, the risk when combined with the perioperative state after major operations is not yet known. Local estrogen therapies for vaginal symptoms of menopause do not increase risk of VTE. CONCLUSION: Given the frequent utilization of hormonal contraception and MHT, orthopaedic surgeons should consider the use of medications containing exogenous estrogen in the perioperative VTE risk assessment of patients. Further discussion toward the perioperative management of these medications and standardization of care for patients with increased VTE risks should be encouraged.

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.

An observational study of an adjusted patient blood management protocol intended to lower rates of transfusion following total knee arthroplasty in patients with preoperative anemia

BackgroundPatients with preoperative anemia have a higher risk of requiring blood transfusion after major orthopedic surgery due to increased blood loss and closer transfusion thresholds. Various patient blood management (PBM) policies aim to reduce transfusion rates. This observational study aimed to investigate blood loss and evaluate the effectiveness of an adjusted surgical PBM protocol in patients with anemic chronic disease (ACD) undergoing elective total knee arthroplasty (TKA).MethodsA consecutive cohort of patients underwent elective unilateral TKA with an adjusted PBM protocol. The protocol consisted of epoetin (EPO) alfa therapy prescribed by the surgeon, routine administration of tranexamic acid (TXA), and standardized postoperative pharmacologic prophylaxis for thromboembolism. The performance of this PBM protocol was analyzed in patients with a baseline hemoglobin level of less than 12 g/dl. Hemoglobin levels were controlled at admission, on postoperative day (POD) 1, and on POD 7 ± 1. A bleeding index (BI-7) was used as an estimate of blood loss up until POD 7. Multiple linear regression was used to assess whether there were any differences in BI-7 between ACD– and ACD + patients.ResultsA total of 751 patients with complete hemoglobin monitoring were included in the study. Of these patients, 68 (9.1%) had a baseline hemoglobin concentration of less than 12 g/dl (ACD group). In this group, 28 patients (41.2%) received preoperative EPO therapy. The mean adjusted BI-7 for the study population was 3.0 (95% CI, 2.9 to 3.0) g/dl in the ACD– group and 2.3 (95% CI, 2.0–2.6) g/dl in the ACD + group. The difference in BI-7 was statistically significant (difference, 0.6 [95% CI: 0.3 to 0.9] g/dl, p < 0.001). No major complications occurred in the ACD + group, whereas there were three complications in the ACD– group (p = 1.00).ConclusionsACD patients undergoing TKA did not have an increased risk of bleeding or bleeding complications with the use of the adjusted PBM protocol. None of ACD patients required transfusion. ACD patients undergoing TKA experienced significantly less blood loss than patients with no preoperative anemia with the use of the adjusted PBM. We now consider the use of EPO in ACD patients with no nutritional deficiencies undergoing TKA at a baseline hemoglobin level of 11 g/dl. However, this should be validated in larger cohorts with a higher prevalence of ACD patients.

CO165 Validation of High Risk Criteria in Medication Reconciliation in Major Orthopedic Surgery: A Delphi Study

CO165 Validation of High Risk Criteria in Medication Reconciliation in Major Orthopedic Surgery: A Delphi Study

Analysis of risk factors for surgical site infection in patients undergoing major orthopedic surgery

Analysis of risk factors for surgical site infection in patients undergoing major orthopedic surgery

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BackgroundMood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.MethodsThis is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not.The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.DiscussionOur trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Effects of Prolonged Tourniquet Application on Coagulation and Fibrinolysis in Rats

Background Pneumatic tourniquets are routinely used in major orthopedic surgeries such as total knee arthroplasty (TKA) to occlude arterial flow, control perioperative bleeding, and facilitate an unimpeded surgical field 1,2,3. Despite its common use, studies have shown prolonged tourniquet application to be associated with up to a 10% symptomatic incidence of thromboembolic events such as deep vein thrombosis and pulmonary embolism, which are major postoperative complications associated with increased morbidity and mortality. Objectives To evaluate hematologic [Von Willebrand factor (VWF), tissue plasminogen factor (TPA) and D-Dimer (DD)] and histopathologic effects of prolonged tourniquet application in Sprague Dawley rats (SD). Methods Male SD rats (n=37) weight ~325 grams were randomized to an experimental group (n=19) and control group (n=18). Under isoflurane anaesthesia, a cable zip-tie emulating a pneumatic tourniquet was applied around the hind-limb of experimental animals, immediately distal to the head of the femur, at a standardized tightness of 38 newtons using a standardized cable tie hand tool for 3-hours. Control animals remained anaesthetized for the same 3-hour period, but without tourniquet intervention. After 3-hours, the tourniquet was carefully removed on experimental animals. Then in all animals, tail vein blood samples were collected, animals were euthanized and tissue samples of distal vessels (femoral and saphenous arteries and veins) and surrounding soft tissues were extracted. All hematologic parameters were measured using respective Asserachrom antigenic kits (Diagnostic Stago), an enzyme immunoassay by ELISA method. Histologic investigation included a modified Carstairs stain for fibrin and platelets as well as routine hematoxylin-eosin (H&amp;E) staining. Results As can be seen in Figure 1, tourniquet application in the hind limb of experimental animals resulted in complete occlusion of arterial flow distal to the device, leading to bruising, muscle stiffness and bleeding into the local tissue, and associated tissue ischemia. The experimental animals exhibited elevated plasma concentration of DD (289.3 ng/mL vs 67.37 ng/mL, p&amp;lt;0.05), VWF (3.4% vs 2.9%, p=0.19) and TPA (11.4 ng/mL vs 1.0 ng/mL, p&amp;lt;0.05) when compared to its control group (Figure 1). The gross and microscopic evaluation revealed varying degrees of vascular congestion and the presence of post-mortem clot formation in the examined samples. No histological evidence of antemortem thrombosis was observed in either group in the microscopic examination of H&amp;E slides. Conclusion Our animal model demonstrates prolonged tourniquet application to be associated with activation of the coagulation and fibrinolysis cascade, but did not demonstrate histological evidence of antemortem thrombosis. Future animal studies are required to compare the prevalence of thrombosis in the post-operative/tourniquet period, which would mimic the temporality of DVT development in a clinical orthopedic setting. Figure 1: Left: hind limb of control animal after 3 anesthetised hours of no tourniquet application. Right: hind limb of experimental animal after 3 anesthetised hours of prolonged tourniquet application. Bleeding into local tissue, and vascular and muscular tissue damage are visible. Bottom: Microscopic examination of hindlimb blood vessel. H&amp;E staining demonstrating (A) artery, (B) vein, and (*) erythrocytes aggregation (20x magnification). There was no evidence of thrombosis.

Overcoming Hurdles in Hemophilia Care: The Impact of World Federation of Hemophilia Humanitarian Aid on Arthroplasties and Orthopedic Surgeries in Low-Middle-Income Setting

Introduction: Hemophilia is a hereditary bleeding disorder characterized by the absence or deficiency of clotting factors, leading to prolonged bleeding and joint damage. In lower-middle-income countries (LMICs) like India, access to standard care for hemophilia has been limited, resulting in many children not receiving prophylaxis and developing severe joint disease in young adulthood. This significantly impacts their quality of life and productivity. Arthroplasty has offered hope for hemophiliacs with established joint disease, but its accessibility in LMICs faces numerous hurdles, including lack of laboratory diagnostics and monitoring facilities, shortage of hematologists, absence of advanced orthopedic surgical teams, limited insurance coverage, and inadequate access to clotting factor concentrates (CFCs) to support surgeries. Comprehensive care centers can address some challenges, but the availability of CFCs remains crucial for effective corrective arthroplasties and other orthopedic surgeries. Aim: This retrospective analysis aims to assess the impact of the World Federation of Hemophilia (WFH) humanitarian aid in facilitating effective corrective arthroplasties and other orthopedic surgeries at a comprehensive care center in a lower-middle-income country. Methods: The study was conducted at a comprehensive care center in India that previously lacked access to CFCs until the initiation of WFH humanitarian aid. Clinical data of patients with hemophilia who underwent major orthopedic surgeries and received CFC support from WFH humanitarian aid between November 2017 and June 2023 were reviewed. Patients with inhibitor-positive status were excluded. Patients were assessed in a comprehensive clinic prior to the elective arthroplasty. The analysis evaluated the utilization of CFCs in orthopedic surgeries, immediate surgical outcomes, and the effect of regulating CFC dose guided by lab monitoring. Additionally, the study audited the impact on CFC utilization when performing two surgeries in one sitting. Data analysis was performed using SPSS version 20.Continuous variables are depicted as mean±SD or median with range. Percentages represent categorical variables. Results: The study included 21 patients with Hemophilia {19 Hemophilia A(90%) and 2 Hemophilia B(10%)} who underwent orthopedic surgeries with CFC support from WFH humanitarian aid.There were 18(85%) patients with severe Hemophilia.Elective arthroplasty was done in 17 patients (81%) and 4 patients(19%) underwent emergency internal fixation. The median age of patients who underwent surgery was 31(range 18-75) years. Elective unilateral knee arthroplasty was done in 7(33%)patients, hip arthroplasty in 2(10%)patients and elbow arthroplasty in 1(5%)patient.Bilateral knee arthroplasty was done in a single surgical setting for efficient CFC utilization in 7 (33%) patients. Extended Half-life (EHL)CFC was used in 10 patients (48%), Standard half-life (SHL) CFC in 2 patients (10%), while the others received a combination of both. Mean use of CFC was 410(Range 270-767) units/kg in Hemophilia A and 650(range 500-800)units/kg in Hemophilia B. The mean EHL FVIII utilization in Bilateral TKR was 400 (Range 322-536) units/kg. None of the patients experienced major intraoperative bleeding or post-operative thromboembolism.No patient developed inhibitor positivity when tested post operatively. Notably, CFC utilization in all patients was found to be less than the empirically recommended levels in WFH guidelines for resource-constrained settings. Table 1 demonstrates the demographics, Type of surgery, CFCs used and immediate outcomes of orthopaedic surgeries done using WFH Humanitarian Aid. Conclusion: The findings of this retrospective analysis demonstrate the transformative impact of WFH humanitarian aid in a comprehensive care center for hemophiliacs in a lower-middle-income country. With access to CFCs, effective corrective arthroplasties and orthopedic surgeries were made possible, providing hope and improved quality of life for patients with established joint disease. The study underscores the vital role of WFH humanitarian aid in enhancing care outcomes for hemophiliacs in resource-limited settings and emphasizes the need for continued support and collaboration to advance hemophilia care globally.

Compliance status and influencing factors of anticoagulation therapy in outpatient undergoing major orthopedic surgery.

This study was designed to investigate influencing factors of out-of-hospital anticoagulation therapy compliance among patients undergoing major orthopaedic surgeries. A cross-sectional, descriptive study was conducted from July 2022 to February 2023 among outpatients who underwent major orthopedic surgery in our hospital. Patients (n = 200) were surveyed using the General Information Questionnaire, the General Self-Efficacy Scale, the Specificity of Medication-Taking Beliefs Scale, and the Morisky Medication Adherence Scale. Factors that influenced patient compliance were also determined using univariate and multivariate regression analyses. One hundred eighty-three valid questionnaires were returned, the compliance with outpatient anticoagulation therapy among patients undergoing major orthopaedic surgeries was good in 56.3% (103/183) of all cases and poor in 43.7% (80/183). Multivariate logistic regression analysis showed that medication duration, adverse effects, self-efficacy and medication beliefs influenced adherence to out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery (P < 0.05). Poor compliance with out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery is mainly associated with a long course of medication, adverse reactions, low self-efficacy and low medication beliefs. Healthcare staff should strengthen post-discharge anticoagulation management based on relevant influencing factors to enhance patient compliance.

The efficacy and safety of aspirin in preventing venous thrombosis in major orthopedic surgery: An updated meta-analysis of randomized controlled trials.

Major orthopedic surgery, including hip and knee replacement and lower extremity trauma fractures surgery, is associated with a high risk of venous thromboembolism (VTE), especially proximal deep vein thrombosis (DVT), and pulmonary embolism (PE), and is linked with high morbidity and mortality rates. Chemical anticoagulation is routinely used to prevent VTE, with previous meta-analyses reporting on the efficacy and safety of aspirin and other anticoagulants, however, opinions are divided. In the past 2 years, several large randomized controlled trials have been published, therefore, we reanalyzed aspirin efficacy and safety when compared with other anticoagulants in preventing VTE in major orthopedic surgery. Using PubMed, The Cochrane Library, Embase, and Web of Science databases, we conducted a RCT search in August 2023. The main outcomes included VTE, proximal DVT or PE. Additional outcomes included bleeding events, wound complications, wound infections, blood transfusions, and death events. In total, 17 eligible articles, involving 29,522 patients (15,253 aspirin vs 14,269 other anticoagulant cases), were included. Primary outcomes showed that VTE incidence was more high in the aspirin group when compared with other anticoagulants (risk ratio [RR] = 1.45, 95% confidence interval [CI] = 1.18-1.77, P = .0004) and proximal in the aspirin group the DVT and/or PE incidence was significantly higher in the aspirin group when compared with other anticoagulants (RR = 1.19, 95% CI = 1.02-1.39, P = .03). No significant secondary outcome differences were identified in the aspirin group when compared with other anticoagulants (bleeding events [RR] = 0.83, 95% CI = 0.63-1.10, P = .20); wound complications (RR = 0.45, 95% CI = 0.20-1.04, P = .06); wound infection (RR = 1.08, 95% CI = 0.85-1.38, P = .53); blood transfusion events (RR = 1.00, 95% CI = 0.84-1.19, P = 1.00) and death events (RR = 1.11, 95% CI = 0.78-1.57, P = .55). Our updated meta-analysis showed that aspirin was inferior to when compared with other anticoagulants in VTE-related orthopedic major surgery, including proximal DVT and/or PE, and was more likely to form VTE. No differences between groups were identified for bleeding, wound complications, wound infections, transfusion, or death events.

Examining the adequacy of preoperative informed consent in a developing country: Challenges in the era of surgical specialisation.

Preoperative informed consent is a legal and ethical requirement that ensures patients understand a procedure, its associated risks and benefits, alternative treatment options, and potential complications to make an informed decision about their care. This cross-sectional study evaluated the informed consent process for major orthopaedic surgeries at a tertiary hospital in Nigeria. A self-administered questionnaire was used to collect data from 120 adult participants. Results showed that many patients do not read the consent form before signing it, and surgeons do not adequately explain the alternatives to surgery, potential risks, and available anaesthetic options. Higher-educated patients are more likely to read the consent form. Surgeons performed well in explaining the nature of the condition and prognosis, the procedure's potential benefits, and answering patients' questions. The study emphasises the need to improve the informed consent process to ensure patients understand and can make rational decisions about their healthcare.

Why Treat Patients with a Major Orthopaedic Surgery Only to Send Them Back to the Vulnerable Conditions That Made Them Sick in the First Place? A Conceptual Scenario to Improve Patient's Journey.

Individuals with severe cartilage degeneration of the hip or knee or collapsed vertebrae that cause spine deformities can suffer from joint and neuropathic pain in the back, disuse of the affected limb, and restriction of movements. Surgical intervention is the most widespread and successful solution to date. There is a general belief that eating healthy and staying physically and mentally active might have a preventive role against musculoskeletal disease occurrence, while instead, we are more certain of the benefits deriving from a healthy diet and exercise therapy after major orthopaedic procedures. These aspects are in fact vital components in enhanced recovery after surgery programmes. However, they are applied in hospital settings, are often centre-dependent, and lack primary and tertiary preventive efficacy since end once the patient is discharged. There is the lack of initiatives at the territorial level that ensure a continuum in the patient's journey towards orthopaedic surgery, home transition, and a healthy and long-lasting life. The expert panel advocates the integration of an intermediate lifestyle clinic that promotes healthy eating, physical activity, and sleep hygiene. In this facility directed by professionals in enhancing recovery after surgery, patients can be referred after the surgical indication and before home discharge. Surgery is in fact a moment when individuals are more curious to do their best to heal and stay healthy, representing a timepoint and opportunity for educating patients on how lifestyle changes may optimise not only their surgical recovery but also long-term future health state.

OC 12.3 Rates of Venous Thromboembolism and use of Thromboprophylaxis After Major Orthopedic Surgery in Patients with Congenital Hemophilia A or B: A Systematic Review

OC 12.3 Rates of Venous Thromboembolism and use of Thromboprophylaxis After Major Orthopedic Surgery in Patients with Congenital Hemophilia A or B: A Systematic Review

Analysis of risk factors for surgical site infection in patients undergoing major orthopedic surgery

Analysis of risk factors for surgical site infection in patients undergoing major orthopedic surgery

869 Gender Distribution of Invited Speakers at Major Trauma and Orthopaedic Surgery Conferences: A Retrospective Open Cohort Study

Abstract Aim Females are disproportionately under-represented in surgery despite the upward trend in women entering the medical profession. Visibility of female surgeons at academic meetings has proven to be an important facet of gender equity. We aim to quantify the proportion of female faculty and prevalence of all-male speaking panels (“manels”) at major T&amp;O surgery meetings. Method We retrospectively analysed four major annual T&amp;O meetings between January 2016 and December 2021. Data was collected on invited lecturers, panelists and chairs/moderators. Male and female faculty were academically stratified according to mean publications, citations, and H-index. A “manel” was defined as a session with 2 or more speakers, all of whom are men. Sex was defined by gender titles used in the conference program, online speaker biography, or the Gender Balance Assessment Tool. Results A total of 968 sessions with 6582 speakers across 18 conferences were identified. The mean percentage of female faculty (invited lecturers, panellists and chairs) was 4.90% (n = 323). Of 775 panel sessions, 568 (73.3%) were manels. No statistically significant difference in the percentage of manels was observed between online (77.8%) versus in-person conferences (72.8%) (p = 0.3195). No statistically significant difference in the proportion of manels was observed over time (from 76.1% in 2016 versus 76.7% in 2021; p = 0.26). Male invited lecturers had a significantly higher H-index than female invited lecturers (p&amp;lt;0.05). Conclusions Manels are highly prevalent in major T&amp;O surgery meetings whilst there is poor representation of female speakers. This study highlights the need for greater gender diversity and female representation in T&amp;O.

Pharmacological Thromboprophylaxis in People with Hemophilia Experiencing Orthopedic Surgery: What Does the Literature Say in 2023?

This narrative review of the literature, consisting of papers found in PubMed and The Cochrane Library published up to 31 July 2023, analyzed those that were deemed to be closely related to the title of this paper. It was encountered that the peril of deep vein thrombosis (DVT) in people with hemophilia (PWH) after orthopedic surgery is very small, such that pharmacological thromboprophylaxis is not necessary in most cases. The hemophilia literature states that the use of pharmacological thromboprophylaxis should only be performed in PWH undergoing major orthopedic surgery (total-knee arthroplasty, total-hip arthroplasty, ankle arthrodesis) who have additional venous thromboembolism (VTE) risk factors, such as old age, prior VTE, varicose veins, general anesthesia, cancer, factor V (Leiden) mutation, overweight, and treatment with the oral contraceptive pill (in females with von Willebrand's illness). If we notice various risk factors for VTE in PWH who experience orthopedic surgery, theoretically, we should perform the identical type of pharmacological thromboprophylaxis advised for non-hemophilia patients: low-molecular weight heparins (LMWHs), such as enoxaparin (40 mg subcutaneous/24 h); or direct oral anticoagulants (DOACs), either thrombin inhibitors (dabigatran, 150 mg oral/12 h) or activated factor X (FXa) inhibitors (rivaroxaban, 20 mg oral/24 h; apixaban, 5 mg oral/24 h), or subcutaneous fondaparinux (2.5 mg/24 h subcutaneously). However, the review of the literature on hemophiliac patients has shown that only a few authors have used pharmacological prophylaxis with LMWH (subcutaneous enoxaparin) for a short period of time (10-14 days) in some patients who had risk factors for VTE. Only one group of authors used a low dose of DOAC in the dusk after the surgical procedure and the next day, specifically in individuals at elevated risk of VTE and elevated risk of bleeding after the surgical procedure.

Effect of Sex Difference on the Analgesic Response of Nalbuphine after Major Orthopedic Surgery in One Egyptian Intensive Care

Abstract Background Several reviews on the topic of gender differences in pain mechanisms, control and treatments have been published in the last two decades. The increasing literature refers to a broad range of topics, including preclinical studies on mechanisms underlying male and female diffelences in nociception and its control, clinical lesearch on gender differences in pain perception and modulation, epidemiological investigations of sex differences in pain prevalence and a growing number of studies examining sex differences in responses to pain therapies. Aim of the Work To compare Egyptian male and female response to Nalbuphine as analgesia after major orthopedic surgery in the intensive care unit, as regards dose effectiveness and adverse effects, in the first postoperative 24 hours. Patients and Method: This comparative prospective analytical study was performed at Ain Shams University Hospitals. The study enrolled 100 Egyptian postoperative patients admitted to ICU after major orthopedic surgery; including 50 females and 50 males. Results The mean age of the participants was 48.81 ± 8.99 years. Regarding the primary outcome, the current study showed that males required a higher dose of nalbuphine than females with a pvalue &amp;lt; 0.001. There was no statistically significant in the VAS score of pain intensity between males and females at all times. Conclusion The results of this study suggest that postoperative nalbuphine requirements differ between Egyptian female and male patients undergoing major orthopedic surgeries. Males require a higher dose than females. But there was no statistically significant difference between females and males regarding postoperative analgesia complications. Nevertheless, funher studies on the ICIationship between the analgesic effect and other factors like comorbid mental disorders are required.