Orthopedic Surgery Research Articles

Feasibility, Safety, and Efficacy of Segmental Spinal Anesthesia with Predominantly Isobaric Levobupivacaine: A Tertiary Care Hospital Study

Objective: To assess feasibility, safety, and efficacy of segmental spinal anesthesia with isobaric levobupivacaine in patients undergoing various abdominal and lower limb surgeries. Methods: This was a prospective cohort study conducted at the department of anesthesiology and critical care of Kota heart institute and group of hospitals in India. The study involved 100 patients undergoing various abdominal and lower limb surgeries under segmental spinal anesthesia (SSA). Isobaric levobupivacaine 0.5% with fentanyl 20-25 μg or dexmedetomidine 5-10 as adjuvant or hypobaric levobupivacaine 0.167% was injected in intervertebral space depending on the surgery. Hemodynamic parameters, postoperative pain level, and adverse effects were analyzed with a p-value less than 0.05 was considered statistically significant.Results: An overall male predominance was observed with a 1:0.515 male-to-female ratio. The most affected age group was 41-50 years (37%), with a mean age of 44.51 ± 11.72 years. ASA classification indicated 34% of patients in ASA I, 40% in ASA II, 24% ASA III and 2% in ASA IV . The primary surgery was laparoscopic cholecystectomy (26%) in normal risk group and orthopedic in high-risk group(20%). Postoperative pain assessment showed mean VAS scores ranging from 1.92 to 3.42 at different time intervals. Common adverse effects were hemodynamic instability (13%), shoulder tip pain (33%), PONV (3%), headache (6%), pruritis (2%) and urinary retention (1%). The hemodynamic instability showed less incidence in ASA III/IV category.Conclusion: Segmental spinal anesthesia can be used successfully for abdominal and lower limb orthopedic surgeries in patients of ASA I to ASA IV.

Early Supported Discharge for Older Adults Admitted to Hospital after Orthopaedic Surgery: A Systematic Review and Meta-Analysis

Abstract Background Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints. Methods A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used, and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1. Results Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (REM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%, P < 0.00001). No statistically significant effects favouring ESD interventions were established in secondary outcomes. Conclusion In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Orthopaedic surgery residents with a mentor report greater self-assessed theoretical and practical preparedness than residents without a mentor.

The purpose of the study was to investigate the effect of mentorship on self-perceived theoretical and practical skill levels of German-speaking residents affiliated to a scientific society with a focus on sports medicine. It was hypothesized that orthopaedic surgery residents with a mentor would report higher subjective theoretical and practical skills and less apprehension towards performing surgeries unsupervised compared to those without mentors. A 35-item questionnaire was distributed among resident members of AGA-Society for Arthroscopy and Joint-Surgery. The survey explored the current status of mentoring and self-assessed theoretical and practical skill levels as well as apprehension towards performing surgeries unsupervised (1-10 scale with higher values indicating higher skill level or greater apprehension). In total, 115 residents were included, of which 46 (40.0%) had a mentor. The majority of residents without a mentor (65.7%) reported the desire to have a mentor. Residents with a mentor reported significantly higher self-assessed theoretical (p = 0.003) and practical skill levels (p < 0.001) and less apprehension towards performing surgeries unsupervised (p < 0.001) compared to residents without a mentor. The presence of formal mentorship programs increased the likelihood of having a mentor significantly (odds ratio [OR] 7.17, p < 0.001). Male and female participants did not differ significantly in self-assessed skill level or apprehension towards performing surgeries unsupervised. Residents with a mentor reported greater subjective skill levels and stated less apprehension towards performing surgeries unsupervised compared to residents without a mentor. The majority of residents without a mentor stated that they would like to have a mentor. This may be achieved by establishing more formal mentorship programs as they facilitate mentorship. Level IV, cross-sectional study.

An Evaluation of Patient Profiles and Outcomes in an Off-Site Rehabilitation Unit in 2023 Compared to 2019

Abstract Background Our off-site inpatient rehabilitation unit accepts patients from many different referral centres. Demographic shifts have occurred in the last 4 years with the Covid-19 pandemic resulting in several practice changes and frailty admissions increasing at our primary referral centre by 11%. We compared the number of patients, their demographics and dependency in 2023 in comparison with 2019 and hypothesised a longer length of stay could be explained by increased dependency as defined by Barthel score on admission. Methods Data regarding patients’ age, admission and discharge dates, referral source and discharge destination were extracted from the rehabilitation unit's database. Weekly MDT records were examined to identify the patients’ presentation and dependency level. Presentations were categorised as stroke, hip fracture, other fracture, acute medical and surgical presentations, and elective surgical procedures. Results Discharges decreased to 89 in 2023 compared to 125 in 2019. Mean length of stay increased to 35.1 from 29.5. Mean age reduced from 85 to 83. Mean Barthel on admission was unchanged at 10. 21 Patients were admitted following elective orthopaedic surgery in 2019 compared to 2 in 2023 with a mean length of stay of 16 days. Length of stay for stroke patients increased from 33 to 50. Excluding both led to a length of stay of 32 in both years. Conclusion The reduction of bed days could be explained by increased frequency of outbreaks and more robust isolation strategies reducing total bed availability. A significant reduction in patients admitted following elective orthopaedic surgery impacted the average length of stay as did an increase in length of stay for stroke patients. Patient dependency defined by Barthel score was not increased and did not explain the increased length of stay. A more comprehensive score such as the Rehabilitation Complexity Score may be more predictive of complexity and thus length of stay.

A Comparison of Nerve Injury in Cross Versus Lateral Pinning Fixation of Displaced Supracondylar Humerus Fracture.

Supracondylar fracture of the humerus (SCFH) is a common pediatric fracture encountered in orthopedic surgery. The most frequently used pinning methods include cross pinning or lateral pinning with two or three pins. However, complications such as ulnar nerve injury can occur, particularly during medial pinning, which necessitates careful isolation of the ulnar nerve and expert surgical intervention. The objective of this study is to compare nerve injury in cross versus lateral pinning fixation of the SCFH. The observational study was conducted at Sheikh Zayed Hospital, Rahim Yar Khan, PAK. Patients in group L (n=55) underwent lateral pinning, while those in group C (n=55) received cross pinning. The patients were followed retrospectively postoperatively until radiological union was achieved. The outcomes were assessed using the Flynn criteria, and nerve injury was evaluated in both groups. The study aimed to compare the postoperative results between the two groups based on the specified criteria. The mean age was 7.28±2.03 years in group L and 8.20±2.21 years in group C. The majority of patients in both groups were male. The left side was more commonly involved, and among the 110 patients enrolled, most sustained the injury while playing. The mean follow-up period was 21.3±1.4 months for group L and 23.5±0.2 weeks for group C. Nerve injuries were reported in six (5.45%) patients in group C, while no nerve injuries were reported in group L. For type III SCFH, lateral pinning fixation has demonstrated itself to be an effective alternative, yielding excellent functional outcomes. This method not only minimizes the risk of iatrogenic nerve injury, particularly to the ulnar nerve but also provides sufficient stability for the fracture. The results from this study suggest that lateral pinning is a reliable option for treating unstable supracondylar fractures, with a favorable safety profile and outcomes comparable to, if not better than, those achieved with cross pinning. This makes it a valuable technique, especially in settings where the risk of nerve injury is a significant concern.

Morphometric evaluation of suprascapular notch and superior angle of the scapula using three-dimensional computed tomography in the Indian population

BackgroundAmong the various aspects of scapular anatomy, the suprascapular notch has gained attention as its anatomical variation is a predisposing factor for compression of the suprascapular nerve in this region, potentially impacting orthopedic surgery. This study aims to investigate the morphology of suprascapular notch (SSN) and its variation with age and sexual dimorphism. It also seeks to classify and correlate the superior angle of the scapula with the SSN in the Indian population. MethodsA retrospective analysis of 360 computed tomography scans of scapulae of 180 adults was conducted. The morphology of SSN was classified according to Rengachary's classification (types I-VI), and the maximum depth (MD) and maximum width (MW) of SSN were measured. The superior angle of the scapula was classified based on morphological characteristics. ResultsType I SSN was the most prevalent, suggesting lower susceptibility to suprascapular nerve entrapment. Males had significantly greater MD than females. Identical types of SSN and superior angles on both sides of the scapula were statistically significant, though variations on each side were also observed. There was no significant difference in age. The superior angle of the scapula was classified into four types: Hilly, mountain peak, crescent, and chimney, with the hilly type being the most common. No correlation was found between SSN and the superior angle. ConclusionThese findings may provide a comprehensive understanding necessary for accurate diagnoses of related abnormalities and for performing safe and effective endoscopic and open surgical procedures in the suprascapular region.

Postoperative delirium among elderly elective orthopedic patients in Addis Ababa Ethiopia: a multicentere longitudinal study

BackgroundDelirium is a neurocognitive disorder characterized by an acute and relatively rapid decline in cognition, disturbance of consciousness, reduced ability to focus, and shift of attention. It mainly affects elderly patients with an incidence of about 8–23% after an operation. It frequently occurs between 24-hrs and 5 days after surgery. It results in serious medical management problems. Hence, identifying the incidence and associated factors may help prevent and manage its sequel in the elderly.ObjectiveAssessment of the incidence and associated factors of postoperative delirium(POD) among elderly elective orthopedic surgical patients in Addis Ababa public hospitals, Ethiopia, 2024.MethodsA multi-centered longitudinal study was conducted on 220 elderly (age ≥ 65 years) patients in four selected public hospitals of the study area from February 2024 to May 2024, and a systematic sampling technique was used to select the study units. Data was collected through chart review and interviews of patients, and postoperative delirium was assessed using the confusion assessment method (CAM). Both bivariable and multivariable logistic regression models were used for statistical analysis. The strength of association was determined with an adjusted odds ratio (AOR) with a 95% confidence interval(CI) at a p-value of < 0.05.ResultsA total of 220 patients were studied, and the incidence of POD among elderly elective orthopedic surgical patients was 33.7%. Age 65–75(AOR = 0.47, 95%CI (0.226–0.97)), Induction using ketamine (AOR = 1.32, 95%CI(1.109–3.87), p = 0.003)), perioperative opioid use (AOR = 2.20, 95%CI(1.073 4.5313)), intraoperative anticholinergic use(AOR = 2.24,95%CI(1.831–4.235)), recent hospitalization history (AOR = 2.24,95%CI(1.202–4.206)), and transfusion (AOR = 2.83,95%CI(1.295–6.193)) were significantly associated with POD (p < 0.05).Conclusion and recommendationsThe incidence of POD in the study area was high (33.7%); advanced age, hospitalization history, Anesthesia induction by Ketamine, perioperative anticholinergic uses, opioid use, and blood transfusion use were associated factors for postoperative delirium. We recommend giving due attention to elderly patients with advanced age, history of hospitalization, perioperative Ketamie use, perioperative anticholinergic uses, opioid use, and blood transfusion use undergoing elderly elective orthopedic surgery.

Effectiveness and safety of rivaroxaban or low-molecular-weight heparin in non-major orthopedic surgery: a meta-analysis of randomized controlled trials

BackgroundPatients undergoing non-major orthopedic surgery often face an increased risk of venous thromboembolism due to the necessity of immobilization postoperatively. Current guidelines commonly recommend the use of low-molecular-weight heparin (LMWH) for prophylaxis, but it is associated with low patient compliance and certain side effects. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the effectiveness and safety of rivaroxaban or LMWH for thromboprophylaxis following non-major orthopedic surgery.MethodRelevant literature was systematically searched in PubMed, Web of Science, Cochrane Library, and Embase from their inception to October 1, 2023, to evaluate the effectiveness and safety of rivaroxaban or LMWH in RCTs for thromboprophylaxis following non-major orthopedic surgery.ResultsA total of 5 randomized controlled trials involving 5,101 patients were included. There was no statistically significant difference in the preventive effect against venous thromboembolism (VTE) when using rivaroxaban or LMWH following non-major orthopedic surgery (RR 0.80; 95%CI 0.31 to 2.07). In terms of safety, there was also no statistically significant difference in the incidence of bleeding events in patients undergoing non-major orthopedic surgery when using rivaroxaban or LMWH (RR 1.15; 95% CI 0.75 to 1.76).ConclusionIn non-major orthopedic surgery, the risk of venous thromboembolism and bleeding complications is similar when using rivaroxaban or LMWH.

The use of biologic disease-modifying anti-rheumatic drugs does not increase surgical site infection or delayed wound healing after orthopaedic surgeries for rheumatoid arthritis.

To investigate the effect of the use of biologic disease-modifying anti-rheumatic drugs (bDMARDs) on surgical site infection (SSI) and delayed wound healing (DWH) in rheumatoid arthritis (RA) patients undergoing orthopaedic surgery. We retrospectively reviewed the records of 965 elective orthopaedic procedures undertaken in RA patients. The incidences of SSI and DWH were compared between the bDMARDs user and non-user groups. Subsequently, univariate and multivariate logistic regression analyses were performed to evaluate risk factors for SSI and DWH after propensity score (PS) matching. The incidence of postoperative flare-up was also examined. In 965 procedures, SSI and DWH were identified in 12 and 28 cases, respectively. SSI and DWH were identified in 3 and 17 of 414 procedures treated with bDMARDs, respectively. Flare-up occurred in 21 cases. PS matching identified 315 cases in both groups, with no significant difference in incidence between the two groups. No risk factors for SSI were identified, whereas age, diabetes mellitus, foot and ankle surgery and a history of musculoskeletal-related infection were identified as risk factors for DWH. The use of bDMARDs was not associated with an increased incidence of SSI or DWH, with the incidence of flare-up being relatively low.

Frailty as a mediator of postoperative delirium in older adults undergoing orthopedic surgery: A causal mediation analysis

BackgroundPostoperative delirium has a high prevalence in hospitalized older adults. Frail older adults have an increased risk for developing it. Preoperative pain—a common symptom in older adults with orthopedic conditions—shows a connection with frailty through an inflammatory process. However, an association among preoperative pain, frailty, and postoperative delirium remains unexplored among older adults undergoing orthopedic surgery. ObjectivesTo examine the magnitude, direction, and mediation effect of frailty on the association between preoperative pain and postoperative delirium among older adults undergoing orthopedic surgery. DesignA secondary analysis of a prospective cohort study. Setting and participantsA cohort of 200 older adults (60 years and older) who underwent major orthopedic surgery at a university hospital in Thailand was recruited for the study. MethodsParticipants responded to the Demographic and Health Information Form, the Reported Edmonton Frailty Scale-Thai version, and the Thai version of the 4 A's test. Analyses were conducted using a causal mediation analysis with 95 % confidence intervals. ResultsWe found that 12.5 % of participants developed postoperative delirium. For the direct paths associated with postoperative delirium, statistically significant effects were observed for frailty, preoperative pain, and comorbidity. Considering frailty as a mediator of postoperative delirium, a significant positive indirect effect was identified from preoperative pain. Controlling for age and comorbidities, frailty mediated the association between preoperative pain and postoperative delirium in a statistically significant manner; the average direct effect was 0.014 (95 % confidence interval: 0.008–0.020), the average causal mediating effect was 0.002 (95 % confidence interval: 0.000–0.010), the total effects was 0.017 (95 % confidence interval: 0.010–0.020), and the probability mediation accounted for 14 % (95 % confidence interval: 0.031–0.300). ConclusionIntegrating the concept of age-related decline and frailty assessment may offer opportunities to provide disease-specific care and strengthen precision perioperative care, which ultimately enhance quality of life in older adults undergoing orthopedic surgery.

Do Racial Disparities Impact Healthcare Costs and Resource Utilization after Total Joint Replacements?

Background Racial disparities currently exist in healthcare and can have a significant impact on patient outcomes and access to quality care. Previous studies have indicated that black patients are more likely to experience delays in treatment and increased surgical complications. Hispanic patients have more comorbidities and increased complications when undergoing orthopaedic surgeries. The purpose of this study was to evaluate the impact of racial disparities on postoperative complications and readmission rates following Total Joint Arthroplasty (TJA). Methods The largest single healthcare network database was queried to identify total joint arthroplasty patients treated in a single division between 2017 and 2021. Patient demographics including age, race, gender, and comorbidities were collected. Logistic regression and odds ratio point estimate analyses were utilized to assess for associations between race (defined as Whites, Blacks, Hispanics, Asians, and Others) and postoperative medical complications and surgical complications, which were collected for all patients. Patient outcomes included length of stay, hospital readmission status at 30 and 90 days postoperative, and emergency room (ER) visits up to 90 days. Results A total of 16,940 patients were included in this analysis consisting of 62% female, a mean age of 71 years and mean BMI of 29.4 kg/m2 . Racial demographics consisted of 61.6% White, 12.3% Black, 24.1% Hispanic, 0.8% Asian, and 1.2% Other. Race was not significantly associated with increased readmissions at 30 days (p=0.2215) and hispanic patients were 14% less likely to be readmitted within 90 days (p = 0.0208) but were not found to have differences in ER visits when compared to White patients. Black and Asian patients were not significantly more likely to visit the ER within 90 days or to be readmitted to the hospital within 90 days when compared to White patients. Race was not significantly associated with postoperative medical complications or surgical complications. Conclusions This study found a higher readmission rate of up to 20% for total joint arthroplasty patients within 90 days of follow-up. Although race did not appear to be a significant determinant of additional ER visits or readmissions, there was some variation seen amongst Hispanic patients undergoing TJR with a lower likelihood of readmission at 60 and 90 days postoperative.

Nature and Magnitude of Industry Payments to Fellowship Program Directors in Orthopaedic Surgery.

Previous research has highlighted conflicts of interest stemming from industry funding and education of orthopaedic surgeons. This study sought to define the nature and magnitude of industry payments to orthopaedic surgery fellowship program directors (FPDs) in the United States. This was a retrospective cohort study of orthopaedic surgery FPDs during 2021. Data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) and Centers for Medicare and Medicaid Services. Profiles of orthopaedic surgery FPDs were obtained for ACGME-accredited and non-ACGME-accredited training programs. Nonresearch industry payments from 2015 to 2021 were extracted and adjusted for inflation. Temporal trends were analyzed through the calculation of compound annual growth rates. Comparisons were made with nonparametric tests. Of 600 orthopaedic surgery FPDs, 596 received industry funding (99%), which totaled $340.6 million over the study period. A trend toward greater total annual industry payments over the study period was observed (compound annual growth rate = 3.3%, P = 0.009). Most industry payments were for royalties or licensing ($246.6 million, 72.4%) and consulting fees ($53.6 million, 15.7%). The median total payment per orthopaedic surgery FPD was $49,971 (interquartile range [IQR], $291,674), with 22% receiving between $100,000 and $500,000 and 17% receiving more than $500,000. The highest annual industry payments existed in shoulder and elbow ($41,489, IQR, $170,613) and spine surgery ($26,103; IQR, $84,968). ACGME accreditation status did not influence the magnitude of industry compensation to orthopaedic surgery FPDs across subspecialties (P > 0.05). Men had higher total median annual industry payments versus women ($7,799 [IQR, $47,712] versus $1,298 [IQR, $6,169], P < 0.001). Industry payments to orthopaedic surgery FPDs are ubiquitous, but the magnitude varies by subspecialty. Most industry funding was found in shoulder and elbow and spine surgery. Standards for orthopaedic fellowship education, such as those upheld by accrediting bodies, should include guidelines on how FPDs handle and disclose financial relationships with industry.

Do modifiable patient factors increase the risk of postoperative complications after total joint arthroplasty?

Numerous studies demonstrate that modifiable lifestyle risk factors can influence patient outcomes including survivability, quality of life, and postoperative complications following orthopaedic surgery. The purpose of this study was to determine the impact of modifiable lifestyle risk factors on postoperative medical and surgical complications following a total joint arthroplasty (TJA) in a large national healthcare system. A retrospective chart review of a large national health system database was performed to identify patients who underwent TJA between 2017 and 2021. TJA included total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty. Modifiable lifestyle risk factors were defined as tobacco use, narcotic drug abuse, hypertension, and diabetes mellitus. Postoperative medical complications and postoperative surgical complications were collected. Logistic regression and odds ratio point estimate analysis were conducted to assess for associations between postoperative complications and modifiable lifestyle risk factors. Of the 16,940 patients identified, the mean age was 71 years, mean BMI was 29.7kg/m2, and 62% were women. We found that 3.5% had used narcotics, 8.7% were past or current smokers, 24% had diabetes, and 61% had hypertension; in addition, 5.4% experienced postoperative medical complications and 6.4% experienced postoperative surgical complications. Patients who used narcotics were 90% more likely to have postoperative complications (p < 0.0001) and 105% more likely to experience prosthetic complications (p < 0.0001). Similarly, patients with tobacco use were 65% more likely to have postoperative complications (p < 0.0001) and 27% more likely to experience prosthetic complications. Our results demonstrate critical rates of increased postoperative medical and surgical complications after TJA for patients with narcotic abuse, tobacco use, or diabetes mellitus. Furthermore, adopting preoperative interventions and optimization programs informed by our findings on specific modifiable risk factors could aid orthopaedic surgeons in optimizing patient health. III; Retrospective study.

From pain level to pain experience: redefining acute pain assessment to enhance understanding of chronic postsurgical pain

BackgroundChronic postsurgical pain (CPSP) significantly impairs quality of life and poses a substantial healthcare burden, affecting up to a quarter of patients undergoing surgery. Although acute pain is recognised as a predictor for CPSP development, the role of patient experience remains underexplored. This study examines the predictive value of patient experience alongside traditional risk factors for CPSP after orthopaedic surgery. MethodsAn exploratory analysis was conducted on 294 patients from a multicentre randomised clinical trial comparing continuous perineural analgesia and single-injection nerve block in ambulatory orthopaedic surgeries. Patient experience was assessed using the Evaluation du Vecu de l’Anesthésie Générale (EVAN-G) validated questionnaire. Factors associated with CPSP at 90 days after surgery were identified through univariate and multivariate analyses, incorporating patient-reported outcomes and classical variables. ResultsOut of 219 patients with complete data, 63 (29%) developed CPSP at day 90. Multivariate analysis revealed a poor pain experience, as assessed by the pain dimension of EVAN-G on postoperative day 2, as an independent predictor of CPSP (odds ratio 6.45, 95% confidence interval 1.65–25.26, P<0.01). Poor pain experience was associated with an augmented risk of CPSP. ConclusionsThis study underscores the role of patient-reported outcomes, specifically the pain experience dimension captured by the EVAN-G scale, in prediction of CPSP 90 days after surgery. It suggests a shift from conventional assessments of pain intensity to a comprehensive understanding of pain experience, advocating for tailored pain management approaches that could reduce chronic pain, thereby improving patient quality of life and functional recovery.

Use of local treatment in managing infections: Focus on antimicrobial locks, beads, and cement.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The purpose of this review is to describe important considerations with local antimicrobial therapies such as locks, beads, and cement for adjunctive infection management or prevention. Local delivery of antimicrobials with locks, beads, and cement has been used for infection management with retained devices in an effort to improve clinical success. However, their use has been controversial due to conflicting clinical data and logistical issues. Antimicrobial lock therapy (ALT) has been used for both adjunctive treatment and prevention of catheter-related bloodstream infections for certain pathogens and based on patient-specific scenarios. ALT has been a controversial method for sterilizing the catheter lumen by delivering high concentrations of antibiotics with or without heparin into the catheter for prolonged durations. Studies differ regarding the selection and concentrations of antibiotics, dwell duration, presence of heparin in the ALT, clinical outcomes/definitions, and use for prevention or treatment of catheter-related bloodstream infections. Antibiotic beads and cement have been used for various surgical procedures but are predominately considered in orthopedic surgeries. Despite the widespread use of the antibiotic-loaded bone cement in orthopedics, studies differ regarding the selection and concentrations of antibiotics, clinical outcomes/definitions, and use for prevention or treatment of infections. Although antimicrobial locks, beads, and cement are commonly used for adjunctive treatment or prevention of infections, more data are needed to support their use to provide clinical efficacy and safety with consistent antimicrobial selection and logistics.

Calcium phosphate complex of recombinant human thrombomodulin promote bone formation in interbody fusion.

Interbody fusion is an orthopedic surgical procedure to connect two adjacent vertebrae in patients suffering from spinal disc disease. The combination of synthetic bone grafts with protein-based drugs is an intriguing approach to stimulate interbody bone growth, specifically in patients exhibiting restricted bone progression. Recombinant human thrombomodulin (rhTM), a novel protein drug characterized by its superior stability and potency, shows promise in enhancing bone formation. A composite bone graft, termed CaP-rhTM, has been synthesized, combining calcium phosphate (CaP) microparticles as a delivery vehicle for rhTM to facilitate interbody fusion. In vitro studies have demonstrated that rhTM significantly promotes the proliferation and maturation of preosteoblasts at nanogram dosage, while exerting minimal impact on osteosarcoma cell growth. The expression levels of mature osteoblast markers, including osteocalcin, osteopontin, alkaline phosphatase, and calcium deposition were also enhanced by rhTM. In rat caudal disc model of interbody fusion, CaP-rhTM with 800 ng of drug doaeage was implanted along with a polylactic acid (PLA) cage, to ensure structural stability within the intervertebral space. Microcomputed tomography analyses revealed that from 8 to 24 weeks, CaP-rhTM substantially improves both bone volume and trabecular architecture, in addition to the textural integrity of bony endplate surfaces. Histological examination confirmed the formation of a continuous bone bridge connecting adjacent vertebrae. Furthermore, biomechanical assessment via three-point bending tests indicated an improved bone quality of the fused disc. This study has demostrated that rhTM exhibits considerable potential in promoting osteogenesis. The use of CaP-rhTM has also shown significant improvements in promoting interbody fusion.

Do Half of Orthopaedic Surgeons Change Jobs within Their First 2 Years?: An Analysis Using the American Board of Orthopaedic Surgery Database.

The claim that "50% of orthopaedic surgeons leave their first job within 2 years" did not originate from evidence. The purpose of this study was to investigate practice change rates among board- eligible orthopaedic surgeons using the American Board of Orthopaedic Surgery (ABOS) database. We utilized information provided by orthopaedic surgeons taking the ABOS Part II Examination across 6 different years. Surgeons who trained outside of the United States and members of the uniformed services of the U.S. were excluded. Move rates within 2 years of starting practice and before the candidate's Part II examination were determined. All surgeons were then subcategorized as having followed a traditional or nontraditional certification timeline based on whether they took Part II of the examination within 2 practice years after becoming board-eligible. Candidate-specific variables were analyzed according to whether the surgeon did or did not change practices. Among 3,784 orthopaedic surgeons, 215 (5.7%) left their first practice within 2 years. On average, candidates sat for the Part II examination at a mean (and standard deviation) of 2.1 ± 1.1 years (range, 0.7 to 31.9 years) after reporting their first practice location. Seventy-six percent of surgeons took the Part II examination within a traditional timeframe. On average, nontraditional candidates left their first practice at a significantly higher rate than traditional candidates (20.5% versus 1.3%; p < 0.001), changed practices more often (1.5 versus 1.2 moves; p = 0.021), and moved farther (500.1 versus 304.4 miles; p = 0.023). Fellowship training and/or Part II examination subspecialty were not strongly associated with a surgeon leaving his or her first practice. While it is possible that >5.7% of orthopaedic surgeons leave their first job during their early career, it is unlikely that many relocate within 2 years. This is especially true among orthopaedic surgeons pursuing ABOS certification within a traditional timeframe.

Effect of Citrus aurantium Aromatherapy on Pain After Orthopedic Surgery.

Effect of Citrus aurantium Aromatherapy on Pain After Orthopedic Surgery.

3D printing application for orthopedic pediatric surgery – a systematic review

PurposeThis paper aims to present a systematic review of the latest scientific literature, in the context of pediatric orthopedics, on the development by additive manufacturing of anatomical models, orthoses, surgical guides and prostheses and their clinical applications.Design/methodology/approachFollowing the current guidelines for systematic reviews, three databases (Elsevier Scopus®, Clarivate Web of ScienceTM and USA National Library of Medicine PubMed®) were screened using a representative query to find pertinent documents within the timeframe 2016–2023. Among the information, collected across the reviewed documents, the work focused on the 3D printing workflow involving acquisition, elaboration and fabrication stages.FindingsFollowing the inclusion and exclusion criteria, the authors found 20 studies that fitted the defined criteria. The reviewed studies mostly highlighted the positive impact of additive manufacturing in pediatric orthopedic surgery, particularly in orthotic applications where lightweight, ventilated and cost-effective 3D-printed devices demonstrate efficacy comparable to traditional methods, but also underlined the limitations such as printing errors and high printing times. Among the reviewed studies, material extrusion was the most chosen 3D printing technology to manufacture the typical device, particularly with acrylonitrile butadiene styrene.Originality/valueTo the best of the authors’ knowledge, this is the first systematic review which annotates, from a more engineering point of view, the latest literature on the admittance of the clinical application of additive manufacturing (and its effects) within typical pediatric orthopedic treatments workflows.

Development of hydroxyapatite/poly(3‐hydroxybutyrate‐co‐3‐hydroxyvalerate)/gelatin composite nanofibers to improve bone‐forming cell proliferation and mineral deposition

AbstractCalcium phosphate hydroxyapatite (HA) was successfully incorporated into poly(3‐hydroxybutyrate‐co‐3‐hydroxyvalerate)/gelatin (PHBV/GEL) nanofibers through an electrospinning process in a hexafluoroisopropanol solvent (HFIP). The PHBV/GEL was electrospun and collected using a rotating metallic network to develop highly ordered nonwoven mats. The effects of HA addition on the morphologies of the obtained fibers were investigated using SEM. The average diameter of the fibers ranged around 700–900 nm, depending on the HA content. From a mechanical perspective, the addition of HA nanoparticles showed variations in tensile strength and elastic modulus values. The lowest tensile strength measured for neat PHBV/GEL was 0.37 ± 0.08 MPa with an elastic modulus of 9.45 ± 0.65 MPa, whereas the highest tensile strength reported for 5% HA‐loaded PHBV/GEL mats was 1.1 ± 0.4 MPa with an elastic modulus of 16.9 ± 0.39 MPa. In addition, cell viability, and mineral deposition were also studied using MC3T3‐E1 pre‐osteoblasts. The in vitro experiment results showed that the HA loaded‐PHBV/GEL mats provide optimal conditions for cell growth and osteogenic differentiation of MC3T3‐E1 cells. This study reveals the potential of PHBV/GEL/HA matrices in the development of novel guided bone‐regeneration (GBR) membranes for orthopedic and craniomaxillofacial surgery, by providing favorable structural features for attachment, growth, and differentiation of osteoblast cells.Highlights Simple and cheap electrospinning strategy toward network‐like fibrous mats. Microstructure, mechanical, and biological features were evaluated. Electrospun PHBV/GEL/HA promoted calcium phosphate deposition by MC3T3‐E1 cells.