Tertiary Orthopaedic Hospital Research Articles

Can the lung ultrasound score predict pulmonary complications after non-thoracic surgery in patients with blunt thoracic trauma: A single-center observational study

Study objectivePatients with blunt thoracic trauma have a high risk of developing postoperative pulmonary complications (PPCs). In this study, we aimed to identify the risk factors for PPCs after non-thoracic surgery in patients with blunt thoracic trauma and investigate the efficacy of perioperative lung ultrasound scores in predicting PPC occurrence. DesignProspective observational study. SettingA Chinese tertiary orthopedic hospital. ParticipantsThis observational study included 369 patients with blunt thoracic trauma who underwent surgery for pelvic and upper or lower extremity fractures. InterventionsLung ultrasonography was performed pre- and postoperatively. MeasurementsPatients were followed up for 1 week to assess PPCs and assigned to the PPC or non-PPC groups. We identified risk factors for PPCs using univariate and multivariate logistic regression analyses. The predictive value of these risk factors was evaluated using receiver operating characteristic (ROC) curves. Main resultsPPCs incidence was 36.58 %. The two groups differed significantly in Injury Severity Scores, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease, hydrothorax, preoperative hypoxemia, lung ultrasound score, preoperative hemoglobin level, intraoperative infusion volume, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) scores (P < 0.05). Independent risk factors for PPCs included ASA classification III, higher postoperative lung ultrasound scores, preoperative anemia, higher intraoperative infusion volume, and higher ARISCAT scores. ROC curve analysis revealed that postoperative lung ultrasound score (area under the curve [AUC]: 0.810, cutoff: 10), preoperative hemoglobin level (AUC: 0.627, cutoff: 97), intraoperative infusion volume (AUC: 0.701, cutoff: 886.51 ml/h) and ARISCAT score (AUC: 0.718, cutoff: 33) predicted postoperative outcomes effectively. ConclusionsPostoperative lung ultrasound scores reliably predicted pulmonary complications after non-thoracic surgery in patients with blunt thoracic trauma. ASA classification III, preoperative anemia, excessive intraoperative fluid infusion, higher ARISCAT, and postoperative lung ultrasound scores were significant risk factors associated with PPCs.Trial registration: Clinical Trial Number: 1900023408. Registered on May 26, 2019.

The straight head of rectus femoris: An underdiagnosed cause of chronic pain post hip replacement

Groin pain following hip arthroplasty has a spectrum of aetiologies. Although mild post-operative pain at six months to a year is common, other causative factors should be considered where pain is severe or persistent. The rectus femoris (RF) muscle is the most common of the quadriceps tendons to be injured or strained. Pathologies are known to occur in athletic adults and children and include tendinopathy, tear, and avulsion, but the RF is rarely attributed to hip pain post-arthroplasty. However, tendinopathy may occur as a result of altered biomechanics and muscle loading. We performed a retrospective analysis of 100 patients, at our tertiary orthopedic hospital, who presented with chronic pain post hip arthroplasty. We identified three patients with RF straight (direct) head tendinopathy and one patient with RF straight (direct) head calcific tendinopathy. Established causes of chronic post-operative pain include septic/aseptic loosening, pseudotumor, iliopsoas bursitis/impingement, and bursitis. In this report, we describe the scanning technique, sonographic appearances, and our institutional experience of post-arthroplasty pathologies of the RF straight (direct) head which is an underreported cause of chronic pain following hip replacement. We also recommend including the RF straight (direct) head in routine US protocols of the post-operative hip.

A retrospective review of effectiveness of ERAS post-operative pain protocol in hip replacement surgeries under general anaesthesia at a tertiary orthopaedic hospital

: The concept of enhanced recovery after surgery (ERAS) was first introduced in 1997 by a group of European surgeons led by Henrik Kehlet. The ERAS concept was introduced to target the factors delaying post-operative recovery such as organ dysfunction, surgical stress and to improve the surgical outcomes and length of stay at the hospital. The primary aim of this approach is to reduce the body’s response to surgical stress by implementing a multidisciplinary, multitude of interventions in a coordinated clinical pathway. It was first implemented for colorectal surgeries to improve the post-surgical recovery rates by decreasing the post-operative ileus and thereby reducing the cost and length of hospital stay. Since the successful introduction of the program, ERAS has been used in several other specialties such as breast, urological, gynaecological, and musculoskeletal procedures. Off-late ERAS has become important in orthopaedic surgeries, particularly elective hip and knee arthroplasties. A retrospective review audit was conducted at tertiary Orthopaedic NHS Hospital to determine the effectiveness of ERAS post-operative pain protocol in patients who had primary hip arthroplasty under general anaesthesia. The qualitative and quantitative data included the length of stay at the hospital and default rates in the ERAS pain protocol. The length of stay at the hospital in ERAS compliant group was a mean of 3.95 days and in ERAS default group was 4.7 days, showing an increase of 16% in the total duration. The IV PCA group had 4.6 days of the average length of stay.: ERAS pathway advocates for using opioid-sparing multimodal analgesia to control pain, peripheral nerve blocks (single-shot/continuous), and local infiltration /peri-articular injections have become a better alternative to opioids in controlling the immediate post-surgical pain effectively. There is clear evidence to suggest that these techniques can improve patient outcomes and decrease the duration of stay.

Lower microhardness along with less heterogeneous mineralization in the femoral neck of individuals with type 2 diabetes mellitus indicates higher fracture risk

Abstract There is still limited understanding of the microstructural reasons for the higher susceptibility to fractures in individuals with type 2 diabetes mellitus (T2DM). In this study, we examined bone mineralization, osteocyte lacunar parameters, and microhardness of the femoral neck trabeculae in 18 individuals with T2DM who sustained low-energy fracture (T2DMFx: 78 ± 7 years, 15 women and 3 men) and 20 controls (74 ± 7 years, 16 women and 4 men). Femoral necks of the T2DMFx subjects were obtained at a tertiary orthopedic hospital, while those of the controls were collected at autopsy. T2DMFx individuals had lower trabecular microhardness (P = .023) and mineralization heterogeneity (P = .001), and a tendency to a lower bone area with mineralization above 95th percentile (P = .058) than the controls. There were no significant intergroup differences in the numbers of osteocyte lacunae per bone area, mineralized lacunae per bone area, and total lacunae per bone area (each P &amp;gt; .05). After dividing the T2DMFx group based on the presence of vascular complications (VD) to T2DMFxVD (VD present) and T2DMFxNVD (VD absent), we observed that microhardness was particularly reduced in the T2DMFxVD group (vs. control group, P = .02), while mineralization heterogeneity was significantly reduced in both T2DMFx subgroups (T2DMFxNVD vs. control, P = .002; T2DMFxVD vs. control, P = .038). The observed changes in mineralization and microhardness may contribute to the increased hip fracture susceptibility in individuals with T2DM.

Yield of routine mycobacterial culture of osteoarticular specimens in a tertiary orthopaedic hospital in England, 2017-2022.

Introduction: At our tertiary orthopaedic centre, mycobacterial cultures are routinely performed on bone and joint samples sent for bacterial culture. Methods: From laboratory records, we ascertained the number of mycobacterial cultures performed, the number positive for Mycobacterium tuberculosis complex (MTBC) and/or non-tuberculous mycobacteria (NTM), and the characteristics of individuals from whom mycobacteria were isolated. We collected the same data from 100 individuals with negative mycobacterial cultures. Results: Excluding sample types that were not bone or joint samples, 6162 mycobacterial cultures were performed between 4July2017 and 30September2022. A total of 22 patients had MTBC and 6 patients had NTM newly isolated from bone or joint samples placed in mycobacterial culture, while a further 1 patient had both Mycobacterium tuberculosis and Mycobacterium avium isolated. To identify one new mycobacterial infection of bone or joint (MTBC or NTM) that would not have been detected with routine bacterial cultures alone, 229 (95 % CI of 158-347) mycobacterial cultures were needed. Mycobacterial cultures were much less likely to be positive in samples taken from prosthetic joints. They were more likely to be positive in spinal samples and in samples taken from patients with suspected sarcoma. In patients from whom MTBC had been isolated, granulomatous inflammation was reported in 86 % (18 of 21) of contemporaneous histological specimens. Conclusions: Targeted, rather than routine, mycobacterial culture of bone and joint specimens should be considered in settings with a low burden of tuberculosis.

The Environmental Impact and Sustainability of Total Hip and Knee Arthroplasty

BackgroundOperating room waste is disposed of in landfill sites, recycled, or undergoes costly, energy-intensive incineration processes. By assessing the quantity and recyclability of waste in primary hip (THA) and knee arthroplasty (TKA), we aim to identify strategies to improve sustainability. MethodsA prospective waste audit of 15 primary THA and 16 primary TKA cases was conducted at a tertiary orthopedic hospital between April and July 2022. Waste was categorized into nonhazardous, hazardous, recycling, sharps, and linens. Each category was weighed. Items disposed as nonhazardous waste were cataloged for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined using packaging. ResultsAverage total waste generated for THA and TKA was 14.46 kg and 17.16 kg, respectively. TKA generated significantly greater waste (P < .05). Of all waste, 5.4% was recycled in TKA and just 2.9% in THA cases. The mean amount of recycled waste was significantly greater in TKA cases than that in THA cases, 0.93 kg and 0.42 kg, respectively.Hazardous waste made up the largest proportion for both TKA (69.2%) and THA (73.4%). Nonhazardous waste made up 15.1% and 11.3% of total waste for TKA and THA, respectively. In the nonhazardous waste, only 2 items (scrub-brush packaging and towel packaging) were recyclable. ConclusionsWe estimate hip and knee arthroplasty generates over 2.7 million kg of waste in the United Kingdom annually. Currently, only a small percentage of waste is recycled in hip and knee arthroplasty, which could improve through increased use of recyclable plastics and clear labeling of items as recyclable by medical suppliers.

Comparison of patterns and rates of cement leakage in percutaneous sacroplasty for sacral insufficiency fractures versus neoplasia.

Percutaneous sacroplasty is a minimally invasive procedure which utilises injection of bone cement into the sacrum for stabilisation of osteoporotic sacral insufficiency fractures (SIF) and neoplastic lesions to relieve pain and improve function. While effective, cement leakage is an important complication associated with the procedure. This study aims to compare the incidence and patterns of the cement leakages following sacroplasty for SIF versus neoplasia and discuss the various patterns of cement leakage and their implications. This retrospective study analysed 57 patients who underwent percutaneous sacroplasty at a tertiary orthopaedic hospital. Patients were divided into 2 groups of SIF (n=46) and neoplastic lesions (n=11) based on their indication for sacroplasty. Pre- and post-procedural CT fluoroscopy was used to assess for cement leakage. The incidence and patterns of cement leakage were both compared among the two groups. A Fisher's exact test was used for statistical analysis. Eleven (19%) patients had cement leakage on post-procedural imaging. The most common sites of cement leakage were into the presacral region (6), followed by sacroiliac joints (4), sacral foramina (3) and posterior sacral (1). There was a statistically significant higher incidence of leakage in the neoplastic group in comparison to SIF group (P-value <0.05). The incidence of cement leakage in the neoplastic group was 45% (n = 5/11) versus SIF 13% (n=6/46). There was a statistically significant higher incidence of cement leak in sacroplasties conducted for the treatment of neoplastic lesions compared to those with sacral insufficiency fracture.

THE ENVIRONMENTAL IMPACT AND SUSTAINABILITY OF TOTAL HIP AND KNEE ARTHROPLASTY

The National Health Service produces over 500,000 tonnes of waste and 25 mega tonnes of CO2 annually. Operating room waste is segregated into different streams which are recycled, disposed of in landfill sites, or undergo costly and energy-intensive incineration processes.By assessing the quantity and recyclability of waste from primary hip and knee arthroplasty cases, we aim to identify strategies to reduce the carbon footprint of arthroplasty surgery.Data was collected prospectively at a tertiary orthopaedic hospital, in the theatres of six arthroplasty surgeons between April – July 2022. Fifteen primary total hip arthroplasty (THA) and 16 primary total knee arthroplasty (TKA) cases were included; revision and complex primary cases were excluded.Waste was categorised into non-hazardous waste, hazardous waste, recycling, sharps, and linens. Each waste category was weighed. Items disposed as non-hazardous waste were catalogued for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined from packaging.Average total waste generated for THA and TKA were 14.46kg and 17.16kg respectively, with TKA generating significantly greater waste (p &lt; 0.05).On average only 5.4% of waste was recycled in TKA and just 2.9% in THA cases. The mean recycled waste was significantly greater in TKA cases compared to THA, 0.93kg and 0.42kg respectively (p &lt; 0.05).Hazardous waste represented the largest proportion of the waste streams for both TKA (69.2%) and THA (73.4%). On average TKA generated a significantly greater amount (11.87kg) compared to THA (10.61kg), p &lt; 0.05.Non-hazardous waste made up 15.1% and 11.3% of total waste for TKA and THA respectively.In the non-hazardous waste, only two items (scrub brush packaging and sterile towel packaging) were identified as recyclable based on packaging.We estimate that annually total hip and knee arthroplasty generates over 2.7 million kg of waste in the UK. Through increased use of recyclable plastics for packaging, combined with clear labelling of items as recyclable, medical suppliers can significantly reduce the carbon footprint of arthroplasty. Our data highlight only a very small percentage of waste is recycled in total hip and knee arthroplasty cases.

Paper 15: Is Asymmetry of the Medial and Lateral Posterior Femoral Condyles Associated with ACL Rupture: A Case Control Study of Pediatric Patients

Objectives: Rates of anterior cruciate ligament (ACL) injury in the pediatric population have increased in the last 20 years. While many risk factors have been investigated, to the authors knowledge no study has analyzed the difference in the posterior femoral condyles in patients who have sustained ACL rupture. Therefore, this case control study sought to understand the relationship between the medial and lateral posterior condyles, as well as examining distal femoral version. The authors hypothesized that pediatric patients who suffered ACL rupture will have a relatively larger medial posterior femoral condyle leading to increase structural valgus in flexion. Methods: Pediatric patients with a pre-operative knee MRI who underwent ACL reconstruction between February 2016 and June 2020 at a tertiary orthopedic hospital were collected. Cases were matched to controls based on sex, laterality of injury, and age at imaging within 1.5 years. Medial and lateral posterior condylar height was measured for each participant. Condylar difference was calculated as medial posterior condylar height minus lateral posterior condylar height. The distal femoral version was calculated as the angle between the femoral posterior cortical axis and the posterior condylar axis. Mann-Whitney U tests were used to compare continuous variables. Significance was set as a p≤0.05. Results: A total of 72 participants were included in this analysis - 36 cases and 36 controls. Median age was 13.5 ± 3.3 years for all participants. Condylar difference was noted to be 1.8 mm greater in cases than controls (p=0.038), while distal femoral version was noted to be 2.0° greater in cases than controls (p=0.025). Conclusions: This study demonstrated a significantly greater posterior condylar height difference and distal femoral version among pediatric patients who suffered ACL rupture compared to a matched control group. We speculate that this morphology leads to a relative increase in knee valgus in flexion. [Figure: see text][Table: see text][Figure: see text]

Maximum surgical blood ordering schedule for common Orthopaedic surgical procedures at Birrd hospital (Tertiary orthopaedic hospital)

Maximum surgical blood ordering schedule for common Orthopaedic surgical procedures at Birrd hospital (Tertiary orthopaedic hospital)

Oral enzyme combination with bromelain, trypsin and the flavonoid rutoside reduces systemic inflammation and pain when used pre- and post-operatively in elective total hip replacement: a randomized exploratory placebo-controlled trial.

Early mobilization after total hip replacement (THR) is key for fast recovery but is often limited by pain. Oral enzyme combinations (OECs) have demonstrated anti-inflammatory and pain-relieving effects. This prospective, randomized, double-blind, placebo-controlled exploratory trial evaluated the effects of pre- and post-operative use of OEC (90 mg bromelain, 48 mg trypsin, 100 mg rutoside) following elective THR, on post-operative recovery. Candidates for primary elective cementless THR owing to osteoarthritis were eligible for participation [age ⩾50 years, body mass index 25-35 kg/m2, C-reactive protein (CRP) ⩽6 mg/L]. Following randomization to OEC or placebo, intervention started pre-operatively and continued onwards until day 42. Main outcomes included post-operative CRP levels (days 1-7), self-reported hip pain at rest (by 0-10 cm visual analogue scale on post-operative days 1-42), post-operative analgesic use [by cumulative analgesic consumption score (CACS) days 7-42], tolerability and adverse events. Patients (N = 34) were recruited from a tertiary orthopaedic hospital in the Czech Republic, of whom 33 completed the study (OEC/placebo: n = 15/18). Baseline characteristics across the groups were comparable. Compared with placebo, the OEC group had numerically lower CRP levels on post-operative days 1-7, including peak level [mean (standard deviation) OEC versus placebo: 81.4 (28.3) versus 106.7 (63.3) mg/L], which translated into a significant 32% lower CRP area under the curve (p = 0.034). The OEC group reported significantly less pain during post-operative days 1-7 versus placebo (analysis of variance treatment × visit [F(4) = 3.989]; p = 0.005). Analgesic use was numerically reduced as assessed through an accumulated CACS. No deleterious effects on haemorheological parameters were observed in either group. Pre- and post-operative use of OEC significantly reduced CRP levels and patient self-reported pain. OEC may be an efficacious and safe treatment option to facilitate post-operative recovery following THR. EudraCT number 2016-003078-41.

Clinical Features and Management of Seizure After Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

To describe the perioperative clinical features, management, and outcomes of patients with seizure after percutaneous endoscopic spine surgery (PESS). Patients who experienced seizure after PESS in a tertiary orthopedic hospital between January 2016 and June 2022 were retrospectively recruited, and patient charts were reviewed. Twenty-nine patients were recruited, and the incidence of seizure after PESS was 0.52%. The operation time was 110.0 minutes (interquartile range [IQR], 82.5-235.0 minutes) and the irrigation speed was 109.0 mL/minute (IQR, 86.5-145.5 mL/minute). Definitive dural tears were reported in 15 patients (51.7%). In addition to agitation and myotonia, significant increased respiratory rate (29.9 ± 6.5 breaths/minute), tachycardia (112.1 ± 20.6 beats/minute), and hypertension (systolic, 189.5 ± 21.9 mm Hg; diastolic, 98.3 ± 10.6 mm Hg) were observed. Arterial blood gas analysis showed hypocapnia, metabolic acidosis, and hyperlactatemia. All patients received analgesia and sedation as well as hyperosmolar therapy. The estimated duration of seizure was 3.0 hours (IQR, 2.5-4.0 hours) and the postoperative length of hospital stay was 3.0 (IQR, 3.0-5.5) days. The Japanese Orthopaedic Association score and visual analog scale score improved markedly within 6 months after surgery. Despite the low incidence and short duration, seizure after PESS should be considered a critical and urgent syndrome. Management strategies for seizure mainly involve intensive care, securing the airway, analgesia and sedation, hyperosmolar therapy, and negative fluid balance. No significant adverse effects of seizure on clinical outcomes were observed during 6 months of follow-up.

Hypotension following hip fracture surgery in patients aged 80 years or older: A prospective cohort study

BackgroundHip fractures occurring in older patients often result in significant anemia, even hemodynamic disorders and hypoperfusion. The present study aims to investigate the general characteristics of hypotension following hip fracture surgery (HFHFS) and its effect on clinical outcomes. MethodsA total of 168 patients aged ≥80 years who underwent hip fracture surgery at a tertiary orthopaedic hospital from January 1, 2020 to August 31, 2020 were enrolled and followed up for one year. Patients were divided into HFHFS and non-HFHFS cohorts according to blood pressure within 24 h after surgery. General difference comparison, univariate and multivariate regression, and survival analysis were applied to investigate the association between HSHSF and in-hospital and one-year clinical outcomes. ResultsThe incidence of HFHFS was 23.8% (40/168), with a median time to onset of 8.0 (5.0–12.0) hours after surgery. The HFHFS group had more chronic heart disease before injury and experienced more positive fluid balance on the day of surgery (P values were 0.032 and 0.028, respectively). After adjustment for potential confounders, HFHFS was associated with prolonged length of hospital stay (B 2.66, 95% CI 0.22, 5.10; P = 0.033), postoperative cardiac dysfunction (OR 2.92, 95% CI 1.05, 8.11; P = 0.039), and postoperative brain dysfunction (OR 3.51, 95% CI 1.50, 8.23; P = 0.004). HFHFS had no effect on one-year modified Rankin Scale (mRS) (B 0.28, 95% CI -0.28, 0.84; P = 0.322) and one-year mortality (HR 1.07, 95% CI 0.29, 3.96; P = 0.917). ConclusionMany older patients develop hypotension several hours after hip fracture surgery, which may be related with preexisting decline in cardiac reserve in addition to postoperative hidden blood loss. Patients who experienced HFHFS were more likely to have postoperative cardiac and brain dysfunction and longer hospital stay. However, HFHFS had no significant effect on mRS and mortality at one year.

Vasovagal reactions in ultrasound guided musculoskeletal injections: A study of 2,462 procedures

Objectiveto determine the rate of the vasovagal reaction (VVR) in ultrasound guided musculoskeletal injections (USGIs) and to investigate effect of injection site, age, and gender on this rate. Material and methodsRetrospective analysis of all USGIs performed from the 1st of January 2019 to the 31st of December 2019 in single tertiary orthopaedic hospital. Two thousand four hundred and sixty two consecutive subjects undergoing USGIs were included. Statistical analysis used to determine the rate of the overall VVR in USGIs and to determine if site of the injection or joint injected has an effect on this rate as well as age and gender effect. ResultsOverall rate of VVR was 2.3% with shoulder and small joints of the hands and feet are more commonly affected than other sites. Females and patients aged younger than 65 years may be subjected to higher rate of VVR. ConclusionsVVR has an overall low occurrence in USGI. The higher rate of VVR for shoulder and small joints of hands and feet procedures. Care should be taken when positioning a patient prior to the procedure to allow for a VVR in case it happens. VVR are more likely to occur in females and less likely in age more than 65 years.

Brachial Plexus Injury Surgical Service in Time of Coronavirus Disease 2019 Pandemic Experience from a Single Tertiary Orthopaedic Hospital in Indonesia

BACKGROUND: Brachial plexus injury (BPI) is one of the most devastating nerve injuries to the extremities. BPI in adults is an increasingly common clinical problem due to road traffic accident. Injury patterns, the timing of surgery, priority on the recovery of function, and patient’s understanding about the expectations of the prognosis are things that are important to consider before deciding on surgical management. The coronavirus pandemic coronavirus disease 2019 (COVID-19) has significantly affected all sectors, one of which is a surgical practice both in terms of medical personnel and equipment, also patient perceptions of hospital services. AIM: This study will analyze epidemiological data on BPI patients who underwent surgery during the COVID-19 pandemic. METHODS: A retrospective descriptive study of BPI profile in Prof. Soeharso Orthopedic Hospital before (2019) and during (2020) the COVID-19 pandemic. Demographic data, the total number of surgery, type of surgical procedure, and patient origin were collected. We compared to the same period in 2019 before pandemic started. RESULTS: In the data obtained from patients treated or undergoing BPI surgery before pandemic (March 1, 2019 to December 31, 2019) and during the pandemic (March 1, 2020 to December 31, 2020), Indonesia first confirms case was on March 2, 2020, until today. There were 51 and 43 cases, respectively. Panplexal type before the pandemic there were 27 patients (52%), and during the pandemic were 20 patients (46%), the upper type before: during the pandemic was 24 (48%): 23 (54%), and lower type 0 cases. Primary reconstruction before: during the pandemic was 26 (55%): 27 (62%) case, and secondary reconstruction before: during the pandemic was 25 (49%): 16 (38%) case, respectively. CONCLUSION: COVID-19 pandemic has no significant effect in the term of the number of BPI surgery performed. Better outcome in BPI surgery is influenced by the timing of the operation, therefore primary reconstruction remains the main choice for BPI patients with safety concern or health protocols. Pre-operative screening applied in our hospital includes laboratory examination, chest radiograph, and polymerase chain reaction swab test. Surgical personnel using personal protective equipment such as protective suit, face shield, google, shoes and medical mask during the COVID-19 pandemic. Patients with significant axon loss and limited clinical recovery are considered “urgent”, as surgery should be performed within 6 months or sooner (depending upon the distance to recipient’s muscle) to avoid irreversible muscle atrophy and degradation of motor endplates.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology.

COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Effect of Coronavirus Disease-19 Pandemic to the Volume of Total Hip and Knee Arthroplasty Surgical Service: Experience from a Single Tertiary Orthopedic Hospital in Indonesia

The difficult situation of the coronavirus disease (COVID)-19 pandemic may affect to hip and knee arthroplasty service. Retrospective study was performed to patients who received elective total hip/total knee arthroplasty (THA/TKA) from January to September 2020 at Prof. Dr. R. Soeharso Orthopaedic Hospital, Surakarta, Indonesia. There were a total of 64 THA and 227 TKA from January to September of 2020. There was an extreme decrease in the number of TKA surgery during April, May, and June in 2020. The effect of coronavirus disease-19 pandemic to the decrease of arthroplasty service was mainly in the first 3 months period.

Analysis of Posterior Tibial Slope as Risk Factor to Anterior Cruciate Ligament Tear.

Objective The objective of the present study was to evaluate the relationship between patients with anterior cruciate ligament (ACL) injury by indirect trauma and increased posterior tibial inclination. Methods Retrospective study, performed by analysis of medical records and digital radiographs of patients, present in a database of a tertiary orthopedic hospital. The sample consisted of two groups, the first group consisting of patients diagnosed with ACL injury by indirect trauma, and a control group matched by age. Results Each group consisted of 275 patients, whose measurements of posterior tibial inclination were measured by three specialists. It was observed that the group of patients with ACL lesion presented a significantly higher tibial slope (in degrees) than the control group in the total sample and in the subsamples stratified by gender. The best cutoff point for the first group was identified as a posterior tibial inclination ≥ 8°, achieving a sensitivity of 63.3% and a specificity of 62.5%. The first group also had a tibial slope ratio ≥ 8° (63.3%), significantly higher than the control group (37.5%), with an odds ratio of 2.8. Conclusion It was concluded that the increase of the posterior tibial inclination is associated with an increased risk for injury of the ACL by indirect trauma, mainly for values ≥ 8°.

Epidemiology of Traumatic Injuries in the Elderly Patients: A Descriptive Study From a Developing Country

The epidemiology of traumatic injuries in elderly patient fractures varies widely among countries. There is quantitative information to determine the prevalence and gender/age distribution of traumatic injuries in the elderly patient. The aim of the current study was to reveal the prevalence and age and gender distribution of various traumatic injuries in an elderly patient refers to as a tertiary orthopedic hospital in Iran. In a prospective descriptive study, all elderly patients with traumatic injuries attending the Orthopedic Trauma Unit of our center in 2001-2011 were included. Demographic details, the cause of injury, injury classification was recorded. For each gender, we calculated the numbers with fractures, dislocations, soft tissue injuries, ligamentous injuries, and lacerations and derived average age and gender-specific prevalence. During a period of 10 years, a total of 1172 elderly patients were admitted, 588 (50.1%) males, and 584 (49.9%) females. 849 patients (72.4%) had fractures. 323 (27.5%) of the patient had other limb injuries were include soft tissue injuries, lacerations, ligamentous injuries, and dislocations. The three most common fracture sites were proximal femur (40.02%), distal radius/ulna (12.47%), and proximal humerus (6.53%). The most prevalent traumatic injury among the elderly was fractures with a higher rate in females. The most common fracture sites were proximal of the femur and distal of radius and ulna bones.

Managing a Tertiary Orthopedic Hospital during the COVID-19 Epidemic, Main Challenges and Solutions Adopted.

The present paper is a review of the main challenges faced by the management of a tertiary specialty hospital during the COVID-19 pandemic in the northern Italian region of Lombardy, an area of extremely high epidemic impact. The article focuses on the management of patient flows, access to the hospital, maintaining and reallocating staffing levels, and managing urgent referrals, information, and communications from the point of view of the hospital managers over a seven-week period. The objective of the article is to provide beneficial insights and solutions to other hospital managers and medical directors who should find themselves in the same or a similar situation. In such an epidemic emergency, in the authors’ opinion, the most important factors influencing the capability of the hospital to maintain operations are (1) sustaining the strict triage of patients, (2) the differentiation of flows and pathways to create what could be regarded as “a hospital inside a hospital”, (3) tracing and sharing all available information to face the rapidly changing environment, (4) being able to maintain staffing levels in critical areas by flexibly allocating the workforce, and (5) from a regional perspective, being organized along a hub-and-spoke system for critical and time-sensitive networks was key for focusing the hospital’s resources on the most needed services.