Procedures In Orthopaedic Surgery Research Articles

Patients' Opinions on Critical Portions of Surgical Procedures in Foot and Ankle Surgery

Category: Other; Ankle Introduction/Purpose: Over the last decade, simultaneous or overlapping procedures in orthopedic surgery have come under increased media attention and public scrutiny. While little is known about what surgeons consider to be 'critical portions' of the myriad of foot and ankle procedures performed, even less is known about the expectations and opinions of patients themselves. In this study we aimed to elucidate patients' expectations of foot and ankle surgeons regarding their presence at different portions of a given surgery and what portions of a surgery they considered to be 'critical'. Methods: In this survey, data was collected using a questionnaire that was filled out by 49 patients presenting to an orthopedic foot and ankle tertiary referral clinic. The questions were designed around three common foot and ankle procedures: open reduction, internal fixation of fractures (ORIF), Achilles tendon repair, and ankle arthroscopy. For each procedure, the key steps were identified, and the responding patient was asked to characterize each step as 'Always Critical' 'Often Critical' 'Sometimes Critical' 'Rarely Critical' or 'Never Critical.' Additionally, demographics, education level, number of prior surgeries, and profession were also collected from the patients. Data were described using means, ranges, and percentages. Results: Of the 49 patients surveyed, the average age was 52.9 years old; 59% were female and 41% were male; 76% of respondents were college graduates, 8% completed some college, and 12% were high school graduates. Overall, 12% of respondents work in a healthcare related field. The average number of previous surgeries was 2.0, with a minimum of 0 and a maximum of 14. In all three procedures, the steps for which more than 50% of the patients identified as 'Always Critical' were discussion of risks, benefits, and alternatives, marking the surgical site, pre-operative time-out, skin incision for ORIF, soft tissue dissection, reduction of fracture, fracture fixation with hardware, repair of the tendon, and scoping the ankle. Across all three procedures, transferring the patient between operating table and bed, applying a sterile bandage, and applying a splint were categorized as the least critical portions of the procedure (Figure 1). Conclusion: The result of this study offers insight on what the most critical portion of three common foot and ankle procedures from the patient's perspective. Generally speaking, patients perceived initial dissection and even closure to be critical, in addition to procedural elements such as fracture reduction. Ongoing research aims to correlate these findings with the perceptions of foot and ankle surgeons themselves. Nonetheless, it highlights the potential discrepancy in perceptions between clinicians and patients as it pertains to 'critical portions' of a given procedure.

Association of dysglycemia with post-operative outcomes in pediatric surgery

BackgroundPerioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity. ResultsA total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p < 0.001), and sepsis (3.7% vs. 1.3%, p < 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p < 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p < 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49–2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04–1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13–2.97, p = 0.000). ConclusionsPerioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.

Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice.

Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.

Efficacy of leupeptin in treating ischemia in a rat hind limb model.

Prolonged tourniquet use can lead to tissue ischemia and can cause progressive muscle and nerve injuries. Such injuries are accompanied by calpain activation and subsequent Wallerian‐like degeneration. Several known inhibitors, including leupeptin, are known to impede the activity of calpain and associated tissue damage. We hypothesize that employment of leupeptin in a rat model of prolonged hind limb ischemia can mitigate muscle and nerve injuries. Sprague–Dawley rats (n = 10) weighing between 300–400 g were employed in this study. Their left hind limbs were subjected to blood flow occlusion for a period of 2‐h using a neonatal blood pressure cuff. Five rats were given twice weekly intramuscular leupeptin injections, while the other five received saline. After 2 weeks, the animals were euthanized, their sciatic nerves and gastrocnemius muscles were harvested, fixed, stained, and analyzed using NIH Image J software. The administration of leupeptin resulted in larger gastrocnemius muscle fiber cross‐sectional areas for the right (non‐tourniquet applied) hindlimb as compared to that treated with the saline (p = 0.0110). However, no statistically significant differences were found between these two groups for the injured left hindlimb (p = 0.1440). With regards to the sciatic nerve cross‐sectional areas and sciatic functional index, no differences were detected between the leupeptin and control treated groups for both the healthy and injured hindlimbs. This research provides new insights on how to employ leupeptin to inhibit the degenerative effects of calpain and preserve tissues following ischemia resulting from orthopedic or plastic surgery procedures.

Lateral meniscus allograft transplantation without bone plugs: technique and outcomes.

Once considered a non-fundamental structure, the menisci are now known to provide several functions within the knee, including protection of articular cartilage, load-bearing, shock absorption, joint stability, joint lubrification and joint congruity functions. Meniscal tears are one of the most common lesions in knee orthopedics, and partial or total meniscectomies are commonly performed procedures in orthopedic surgery. Despite meniscectomy is well recognized to lead improvement in clinical outcomes, it has been related to early onset knee osteoarthritis and joint degeneration which are associated with pain and functional limitations. Meniscal allograft transplantation has become a viable option for patients under 55 years old that have undergone total or near total meniscectomy and are in a painful state. This procedure can be performed using bone plugs or without bone plugs. In the bone plugs free technique allograft will be presented as a lateral meniscus with a portion of tibial plateau and is then introduced into the joint through an arthroscopic portal and fixed to the capsule with all-inside stitches. The most important aspect required to obtain good clinical results are graft size, anatomic placement and fixation, because extrusion is the most common complication related to meniscal transplantation. Although a lack of long-term follow-up (FU) studies, it has been demonstrated that lateral meniscus transplantation without bone plugs is a minimal invasive surgical procedure that improves the knee function, increases patient physical activity and reduces pain.

Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis.

PurposePostdischarge opioid prescriptions are reportedly much higher in Canada than in other countries. To assess potentially contributing factors, we examined trends after abdominal and orthopedic surgeries in British Columbia (BC).MethodsUsing the BC Ministry of Health’s databases on physician billings, hospital discharge abstracts, and medication dispensations in community pharmacies for the period 2003–2016, we assembled a cohort of 263,056 patients who received laparoscopic appendectomy (LA, 11%), laparoscopic cholecystectomy (LC, 30%), open inguinal or femoral hernia repair (IHR, 20%), total hip arthroplasty (THA, 18%), or total knee arthroplasty (TKA, 22%). Adjusting for covariates using generalized linear modeling, we measured trends in percentages of patients dispensed opioids postdischarge (opioid rate) within 30 days after surgery, by surgery type, opioid type, prior use, surgeon, and trends in morphine milligram equivalents of first dispensations (MME) with 95% confidence intervals (CI).ResultsOpioid dispensation rates rose steadily. Mean annual increases were 1.7% in LA; 1.3% in LC; 0.8% in IHR; 0.9% in THA; and 0.8% in TKA. By 2016, rates were 69% in LA; 76% in LC; 81% in IHR; 88% in THA; and 94% in TKA. Codeine dispensations fell 2.4% (abdominal) and 3.1% (orthopedic) per year while tramadol dispensations increased 3.6% (abdominal) and 1.7% (orthopedic). Hydromorphone dispensations increased 2.9% per year (orthopedic); oxycodone was level at 22% between 2007 and 2014, but then fell. The mean MME rose 8 mg⋅yr-1 (95% CI, 7 to 9) (abdominal) and 61 mg⋅yr-1 (95% CI, 58 to 64) (orthopedic). Variation in rates was greater among abdominal than orthopedic surgeons.ConclusionRising opioid dispensation rates, together with shifts to prescribing higher MME opioids, doubled MME per patient in first dispensations postdischarge after abdominal or orthopedic surgery from 2003 to 2016 in BC.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12630-022-02272-7.

Ascertaining the Readiness of Military Orthopedic Surgeons: A Revision to the Knowledge, Skills, and Abilities Methodology.

Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described. All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market. Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets. The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.

Personalized Hip Joint Replacement with Large Diameter Head: Current Concepts.

Hip arthroplasty is a common procedure in elective orthopaedic surgery that has excellent outcomes. Hip replacement surgery aims to create a “forgotten” joint, i.e., a pain-free joint akin to a native articulation. To achieve such goals, hip arthroplasty must be personalised. This is achieved by restoring: the centre of rotation of the native hip; leg length equality; femoral offset; femoral orientation; soft tissue tension; joint stability with an unrestricted hip range of motion; and having appropriate stress transfer to the bone. In addition, the whole pathway should provide an uneventful and swift postoperative recovery and lifetime implant survivorship with unrestricted activities. At our institution, the preferred option is a personalized total hip arthroplasty (THA) with a large diameter head (LDH) using either monobloc or dual-mobility configuration for the acetabular component. LDH THA offers an impingement-free range of motion and a reduced risk of dislocation. The larger head-neck offset allows for a supraphysiologic range of motion (ROM). This can compensate for a patient’s abnormal spinopelvic mobility and surgical imprecision. Additionally, LDH bearing with a small clearance exerts a high suction force, which provides greater hip micro-stability. With appropriate biomechanical reconstruction, LDH THA can restore normal gait parameters. This results in unrestricted activities and higher patient satisfaction scores. We use LDH ceramic on ceramic for our patients with a life expectancy of more than 20 years and use LDH dual mobility bearings for all others.

The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks.

Background and objectiveThere has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery.Materials and methodsThe data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well.ResultsA total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health.ConclusionThis study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

Preoperative Administration of Aprepitant to Prevent Postoperative Nausea and Vomiting in Children

Background: Aprepitant (Emend ® ), a neurokinin-receptor antagonist, has seen increased use in the treatment of nausea and vomiting in various clinical scenarios. To date, there are limited data regarding its use in the pediatric population. We retrospectively reviewed our experience with aprepitant after its addition to the operating room formulary for prevention of postoperative nausea and vomiting (PONV). Methods: The anesthetic records of patients who received aprepitant were retrospectively reviewed. Demographic, surgical, medication, and efficacy data were retrieved. Results: The study cohort included 144 patients ranging in age from 7 to 17 years and in weight from 24.7 to 208.9 kg. The most common surgical procedures included gastrointestinal surgery, orthopedic surgery, and otolaryngologic procedures. Reasons for the administration of aprepitant included PONV prophylaxis due to risk factors such as type of surgery, duration of surgery, previous history of significant PONV, female gender, and family history of PONV. The majority of the patients (98.6%) received aprepitant in capsule form in a dose of 40 mg (97.9%). Seventeen patients (11.8%) had PONV or received antiemetic agents postoperatively. There were no unplanned admissions related to PONV. No adverse effects related to aprepitant were noted. Conclusions: Aprepitant was effectively introduced to the preoperative regimen as an additional agent for the prevention of PONV. The overall tolerability and efficacy of aprepitant was similar to previous studies, even in a patient population at high risk for PONV. J Curr Surg. 2022;12(1):1-6 doi: https://doi.org/10.14740/jcs457

Overview of Methods to Quantify Invasiveness of Surgical Approaches in Orthopedic Surgery-A Scoping Review.

BackgroundThere is a trend toward minimally invasive and more automated procedures in orthopedic surgery. An important aspect in the further development of these techniques is the quantitative assessment of the surgical approach. The aim of this scoping review is to deliver a structured overview on the currently used methods for quantitative analysis of a surgical approaches' invasiveness in orthopedic procedures. The compiled metrics presented in the herein study can serve as the basis for digitization of surgery and advanced computational methods that focus on optimizing surgical procedures.MethodsWe performed a blinded literature search in November 2020. In-vivo and ex-vivo studies that quantitatively assess the invasiveness of the surgical approach were included with a special focus on radiological methods. We excluded studies using exclusively one or multiple of the following parameters: risk of reoperation, risk of dislocation, risk of infection, risk of patient-reported nerve injury, rate of thromboembolic event, function, length of stay, blood loss, pain, operation time.ResultsThe final selection included 51 articles. In the included papers, approaches to 8 different anatomical structures were investigated, the majority of which examined procedures of the hip (57%) and the spine (29%). The different modalities to measure the invasiveness were categorized into three major groups “biological” (23 papers), “radiological” (25), “measured in-situ” (14) and their use “in-vivo” or “ex-vivo” was analyzed. Additionally, we explain the basic principles of each modality and match it to the anatomical structures it has been used on.DiscussionAn ideal metric used to quantify the invasiveness of a surgical approach should be accurate, cost-effective, non-invasive, comprehensive and integratable into the clinical workflow. We find that the radiological methods best meet such criteria. However, radiological metrics can be more prone to confounders such as coexisting pathologies than in-situ measurements but are non-invasive and possible to perform in-vivo. Additionally, radiological metrics require substantial expertise and are not cost-effective. Owed to their high accuracy and low invasiveness, radiological methods are, in our opinion, the best suited for computational applications optimizing surgical procedures. The key to quantify a surgical approach's invasiveness lies in the integration of multiple metrics.

Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review.

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.

Perspective on the integration of optical sensing into orthopedic surgical devices

.SignificanceOrthopedic surgery currently comprises over 1.5 million cases annually in the United States alone and is growing rapidly with aging populations. Emerging optical sensing techniques promise fewer side effects with new, more effective approaches aimed at improving patient outcomes following orthopedic surgery.AimThe aim of this perspective paper is to outline potential applications where fiberoptic-based approaches can complement ongoing development of minimally invasive surgical procedures for use in orthopedic applications.ApproachSeveral procedures involving orthopedic and spinal surgery, along with the clinical challenge associated with each, are considered. The current and potential applications of optical sensing within these procedures are discussed and future opportunities, challenges, and competing technologies are presented for each surgical application.ResultsStrong research efforts involving sensor miniaturization and integration of optics into existing surgical devices, including K-wires and cranial perforators, provided the impetus for this perspective analysis. These advances have made it possible to envision a next-generation set of devices that can be rigorously evaluated in controlled clinical trials to become routine tools for orthopedic surgery.ConclusionsIntegration of optical devices into surgical drills and burrs to discern bone/tissue interfaces could be used to reduce complication rates across a spectrum of orthopedic surgery procedures or to aid less-experienced surgeons in complex techniques, such as laminoplasty or osteotomy. These developments present both opportunities and challenges for the biomedical optics community.

Incidence of Deep Vein Thrombosis (DVT) in Patients Using A Knee Scooter

Category:Ankle; TraumaIntroduction/Purpose:Functional limitations after lower extremity injury often require the use of an assistive device such as a knee scooter. Many patients find these devices to be easier and more comfortable to use than crutches or walkers. There is concern regarding the possible correlation between scooter use and DVT. Prior literature demonstrated decreased venous flow with the knee flexed, and venous stasis is a known risk factor for DVT1-3. Further, healthy volunteers using a scooter demonstrated a significant decrease in volumetric blood flow rate at the popliteal fossa4. We report the incidence of DVTs after prescription of a scooter following lower extremity injury. We hypothesized that DVT rates would be higher in patients using a scooter compared to rates of DVT in the NSQIP databaseMethods:A retrospective record review of adult patients age 18-74 within the Military Health System (MHS) database between 2010-2020 was completed to identify the total number of patients who were prescribed a knee scooter and those who subsequently developed a DVT. Additional demographic and clinical data were collected on patients who had both a scooter and a DVT. This was compared with recorded 2015 NSQIP data on DVT incidence in major orthopaedic surgery procedures.Results:Between 2010 and 2020, 46,840 of patients within the MHS database were prescribed a rolling scooter after a lower extremity injury or surgery. Of those patients who were prescribed a scooter, 377 subsequently developed a DVT within 90 days of prescription. DVTs were diagnosed on average 26.5 days after scooter prescription. The incidence of DVT of in this population was 0.8%.Conclusion:In the Military Health System database, the use of a knee scooter following lower extremity injury or surgery is associated with a higher incidence of DVT compared to the 2015 NSQIPS incidence of DVT following major orthopedic surgery (0.80% vs 0.55%), and is most frequently diagnosed within 30 days of scooter prescription. Higher level study is needed to confirm these findings and identify risk factors of patients who experience DVTs associated with scooter use after lower extremity injury or surgery.

Predicting the Exception-CRP and Primary Hip Arthroplasty.

Background: While primary hip arthroplasty is the most common operative procedure in orthopedic surgery, a periprosthetic joint infection is its most severe complication. Early detection and prediction are crucial. In this study, we aimed to determine the value of postoperative C-reactive protein (CRP) and develop a formula to predict this rare, but devastating complication. Methods: We retrospectively evaluated 708 patients with primary hip arthroplasty. CRP, white blood cell count (WBC), and several patient characteristics were assessed for 20 days following the operative procedure. Results: Eight patients suffered an early acute periprosthetic infection. The maximum CRP predicted an infection with a sensitivity and specificity of 75% and 56.9%, respectively, while a binary logistic regression reached values of 75% and 80%. A multinominal logistic regression, however, was able to predict an early infection with a sensitivity and specificity of 87.5% and 78.9%. With a one-phase decay, 71.6% of the postoperative CRP-variance could be predicted. Conclusion: To predict early acute periprosthetic joint infection after primary hip arthroplasty, a multinominal logistic regression is the most promising approach. Including five parameters, an early infection can be predicted on day 5 after the operative procedure with 87.5% sensitivity, while it can be excluded with 78.9% specificity.

Intramedullary nail holes laser indicator, a non-invasive technique for interlocking of intramedullary nails

Interlocking of intramedullary nails is a challenging procedure in orthopedic trauma surgery. Numerous methods have been described to facilitate this process. But they are exposed patient and surgical team to X-rays or involves trial and error. An accurate and non-invasive method has been provided to easily interlocking intramedullary nails. By transferring a safe visible light inside the nail, a drilling position appears which use to drilling bone toward the nail hole. The wavelength of this light was obtained from ex-vivo spectroscopy on biological tissues which has optimal transmission, reflectance, and absorption properties. Moreover, animal and human experiments were performed to evaluate performance of the proposed system. Ex-vivo performance experiments were performed successfully on two groups of cow and sheep samples. Output parameters were procedure time and drilling quality which there were significant differences between the two groups in procedure time (P < 0.05). But no significant differences were observed in drilling quality (P > 0.05). Moreover, an In-vivo performance experiment was performed successfully on a middle-aged man. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique in the procedure time (P < 0.05), while the drilling quality is equal to the free-hand technique (P = 0.05). Intramedullary nail holes laser indicator is a safe and accurate method that reduced surgical time and simplifies the process. This new technology makes it easier to interlocking the intramedullary nail which can have good clinical applications.

Opioid reduction and elimination in pediatric surgical patients

Opioid overuse is a national concern. Mitigation strategies include judicious prescribing and encouragement of non-opioid therapies. This quality improvement project aimed to identify physician opioid prescribing and patient usage patterns at a pediatric academic center. Patients who underwent same-day general, orthopedic, or plastic surgery procedures were contacted 7 - 28 days post-operatively. Inquiries were made about opioid usage, non-opioid strategies, and overall pain management satisfaction. A subset of general surgery patients not prescribed opioids was compared to those prescribed opioids. Between August 2017 - May 2020, 558 surveys were obtained. There was a significant increase in the use of non-opioid therapies between 2017 and 2020 (83.5% vs 97%, p=0.04). Almost all patients' opioid prescriptions were filled; however, 78-98% had leftover opioids. Only 20-25% disposed the excess opioids. In subset analysis of general surgery patients, no inguinal hernia or orchiopexy patient who was discharged without opioids required opioids later. More non-opioid patients used other therapies (acetaminophen, heat (p=0.03)); however, pain management satisfaction was higher in the opioid group (99% vs 94%, p=0.01). While our opioid prescribing has decreased, physicians are still prescribing more opioids than patients require. Further education on non-opioid pain therapies and proper disposal of opioids are needed. III TYPE OF STUDY: prospective quality improvement study.

Dual-Functional Nano-Functionalized Titanium Scaffolds to Inhibit Bacterial Growth and Enhance Osteointegration.

Implantable biomaterials play a key role for the success of orthopedic surgery procedures. However, infections remain one of the most damaging post-operative complications that lead to the implant failure. Recently, several approaches have been proposed to avoid or manage implant-associated infections. Among these, an appropriate surface functionalization to confer intrinsic antibacterial properties preserving the osteo-integration ability represents an appealing strategy for the development of innovative implant materials. Titanium and its alloys are the most used materials for manufacturing of both articular and bone skull prostheses as well as dental implants. However, to date there is still a significant clinical need to improve their bioactivity, osseointegration and antibacterial activity. In this study, titanium biomimetic scaffolds are prepared by nano-functionalization with TiO2 (Ti_TiO2) and γFe2O3 (Ti_γFe2O3). Both cytocompatibility and antibacterial activity have been evaluated. Data show that both nano-functionalized scaffolds exhibit a good antibacterial activity towards Staphylococcus aureus, reducing colony number to 99.4% (Ti_TiO2) and 99.9% (Ti_γFe2O3), respectively. In addition, an increase of both human adipose-derived mesenchymal stem cells (hADSCs) cell proliferation (up to 4.3-fold for Ti_TiO2 and 3.7-fold for Ti_γFe2O3) and differentiation has been observed. These data suggest that these nano-functionalized titanium substrates represent promising prototypes for new antimicrobial and osteoconductive biomaterials to be used in the orthopedic field to reconstruct significant bone defect.

Comparative evaluation of polymethylmethacrylate and composite bone cements. Review of the experimental studies results

Current article is a review of experimental studies of different bone cements types and their combinations. Providing of bone fragments stable fixation at osteosynthesis in cases of difficult multifragmental fractures, arthroplasties and other implants using especially in the osteoporosis conditions is a main task of orthopaedic surgery procedures. Polymethylmethacrylate (PMMA) is the first material that is answered to these requirements. The evolution of bone cements resulted in creation of a new composite substance — combination of PMMA and β-threecalciumphosfates (β-TCPh). Combination of these two components allowed to provide high bioabsorbal, osteoconductive and osteointegrative properties along with sufficient durability. In the analyzed works the properties of composite cement CalCemex were evaluated in vivo experiment. It was found that in the case of PMMA penetration of bone tissue into the polymer structure did not occur. Under the conditions of using bone cement with β-TCF admixture, the formation of bone tissue was observed not only on the surface of the implant, but also in the external and internal pores. It is the presence of pores in CalCemex that the authors explain the possibility of penetration of cellular elements, blood vessels and bone formation. Moreover, β-TCPh is included into this material and it is bioresorbed by osteoclasts. This leads to the release of calcium and phosphorus ions and, consequently, simplifies the attachment of the newly formed bone to the bone cement. We assume that composite cement like CalCemex type is a promising material for the treatment of various types of fractures and replacement of bone defects. It should be mentioned that research in this area is ongoing and intensive work is underway to synthesize and study the results of clinical application of composite bone cements with maximum bioactive properties that will not only strengthen bone tissue but also perform osteointegrative function. Key words. Bone cement, polymethylmethacrylate, β-threecalciumphosfates, experiment.

Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

Perioperative pain management remains an important focus of both patient and provider attention in orthopaedic trauma surgery. There is a constant effort to improve pain management while decreasing opioid consumption, and peripheral nerve blocks are a safe and effective way to achieve these two goals. This is particularly relevant because more procedures are being done in outpatient surgery centers, and the need to safely provide analgesia without the systemic risk of opioid medications is paramount. The primary goal of this article was to describe the diagnosis-based approach for the utilization of preoperative peripheral nerve blocks in perioperative care for orthopaedic trauma surgery procedures based on the experience and current practice at our center.