Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%),
Abstract. Aim. This study was aimed to look into factors responsible for delayed mobilization after lower limb arthroplasty and effect on length of stay. Methods. It is an observational study conducted at Kings Mill Hospital from August to October 2021. All patients undergoing primary knee or hip arthroplasty were included in the study, while patients with revision surgeries were excluded. A proforma was designed to record demographics and different variables including medications, type of anaesthesia, orthostatic hypotension,
Background. Adequate pain management is mandatory for patients' early rehabilitation and improvement of outcome after total knee arthroplasty (TKA). Conventional pain management, consisted of mainly opioids, has some adverse effects such as
Background. Immersive virtual reality (VR) demonstrates potential benefits in patients with chronic low back pain (CLBP). However, few studies have investigated the feasibility and the acceptability of introducing immersive VR for use with patients with CLBP and in the Kingdom of Saudi Arabia (KSA). Aim. To investigate immersive VR's feasibility, tolerability, and acceptability as a rehabilitation intervention for adult patients with CLBP and explore the views of relevant Health Care Practitioners (HCPs) in the KSA. Methodology and Methods. A multi-centre, mixed-methods, explanatory sequential design was adopted to test immersive VR's feasibility, tolerability, and acceptability. An uncontrolled feasibility trial was conducted. The immersive VR intervention involved a training session followed by three sessions over one week using commercially available hardware and software. Feasibility outcomes were collected from patients immediately post-intervention. Patients and HCPs were recruited for semi-structured interviews. Results. Thirty-three patients and three HCPs were recruited. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, treatment compliance and fidelity. Adverse events included one who reported aggravation of tinnitus, whereas two experienced
The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting,
Introduction and Objective. Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective was to compare the analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to weak opioids (WO) in the treatment of moderate to severe, nociceptive, chronic pain in knee osteoarthritis patients. Materials and Methods. ArthroTENS study is a phase 3, non-inferiority, multicentric, prospective, randomized, single-blinded for primary efficacy outcome, controlled, in 2-parallel groups, clinical study comparing W-TENS versus WO over a 3-month controlled period with an additional, optional, non-controlled, 3-month follow-up for patients in W-TENS group. The co-primary outcome was KOA pain intensity (PI) at month 3 and the number of adverse events (AEs) over 3 months. Results. The non-inferiority of W-TENS was demonstrated in both the PP and ITT populations. At M3, PI in PP population was 3.87 (2.12) compared to 4.66 (2.37) (delta: −0.79 (0.44); 95% CI (−1.65; 0.08)) in W-TENS and WO groups, respectively. Since the absolute value of the 95% CI of the between-treatments mean PI difference [−1.71, – 0.12] was above 0 in ITT set, the planned superiority analysis was performed, demonstrating that W-TENS was significantly superior to WO at M3 (P=0.0124). At M1 and M3, the W-TENS group reached the absolute minimal clinically important difference (MCID) for an analgesic (1.8 (2.1) and 2.1 (2.3), respectively), corresponding to a 20 mm reduction in PI (interquartile range: 15–30) on a 0–100 mm visual analogic scale – i.e. 2 points on a numerical rating scale – which equates to “much better”. Conversely, in the WO group, a 0.5 (1.8) and a 1.1 (2.1) reduction in PI were observed at M1 and M3, respectively, while a 1-point reduction in PI is required to be considered as a “slightly better” improvement. In WO group, AEs were the common systemic AEs reported with WO (nausea, constipation, drowsiness,
Purpose of the study. The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision. Methods. This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging. Results. Thirty-three participants were recruited and a total of 45 interviews being carried out. 7 central themes and 17 sub-themes were generated from thematic analysis. The first-line treatment administered to all participants by their G.P was a combination of analgesia. The drugs used included paracetamol, ibuprofen, nefopam, diclofenac, tramadol, morphine, diazepam and baclofen. Neuropathic pain modulating medication such as amitriptyline, gabapentin or pregabalin was widely used. Participants reported that medication simply didn't provide sufficient pain relief at a dose where side-effects were acceptable. Twenty-four interviewees described the negative side-effects of the drugs including nausea,
INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001),
Background. The second generation metal-on-metal (MoM) prosthesis of the hip became a worldwide success in the 90s. However, after the placement of a MoM prosthesis the cobalt ion concentrations raise significantly. This may lead to systemic complaints and even cobalt toxicity. Methods. Sixty-one patients (26F/35M) with both an unilateral and bilateral resurfacing or large-head MoM (LHMoM) hip prosthesis were included. At last follow-up (5.77 ± 1.57 yrs) cobalt concentrations in the blood were determined by ICP-MS. Based on the known cobalt toxicity symptoms we developed a non-validated questionnaire. Analysis was done on two groups; a low cobalt concentration group and a high cobalt concentration group. We used 170 nmol/L as the upper limit of well functioning prosthesis as defined by the Dutch Orthopaedic Society (NOV). Independent samples T test and Pearson correlation coefficient were done. Results. In 61 patients, 70 prosthesis were implanted: 44 resurfacings and 26 LHMoM. Mean cobalt and chromium ion concentrations were 110 ± 138 (9 – 833) and 104 ± 138 (6 – 592) nmol/L. The low cobalt concentration group consisted of 52 patients, while the high cobalt concentration group consisted of 9 hips. With respect to the systemic complaints, the subjects in the high or low group reported no significant differences. A trend towards more complaints with visual problems (75% vs 51.9%, P = .089) and
The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy. Participants were recruited from two community musculoskeletal treatment centres in the UK. Patients were eligible if aged 18 years or older, and had a clinical diagnosis of subacromial impingement syndrome which the treating clinician thought was suitable for treatment with a subacromial injection. Consenting patients were randomly allocated 1:1 to a patient-blinded subacromial injection of CSI (standard care) or APS. The primary outcome measures of this study relate to rates of recruitment, retention, and compliance with intervention and follow-up to determine feasibility. Secondary outcome measures relate to the safety and efficacy of the interventions.Aims
Methods
Unicompartmental knee replacements offer improved function with more rapid recovery compared to TKR. There is no published experience with introducing this procedure as a day case in the UK. We report on our experience with a new protocol allowing the patient to be discharged on the day of surgery. A new combination of anaesthetic and surgical techniques are employed. Paracetamol, ibuprofen and pregabalin are given pre-operatively. Patients receive a GA and a subsartorial saphenous nerve block is administered under ultrasound control. The surgery is performed using a routine minimally invasive technique. The joint and surrounding tissues are infiltrated with a combination of LA and adrenaline. Wound closure is with subcutaeneous suture and tissue glue. Patients are mobilised on the day of surgery and if comfortable discharged on paracetamol, codeine, ibuprofen, tramadol P.R.N and buprenorphine patch. Length of stay, pain scores, presence of nausea/vomiting,
Introduction. The use of narcotic medications to manage postoperative pain after TJA has been associated with impaired mobility, diminished capacity to engage in rehabilitation, and lower patient satisfaction [1]. In addition, side effects including constipation,
Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain.Aims
Methods
Purpose: Whiplash injury occurs due to motor vehicle accidents has its long term consequence, nevertheless very little is written about its long-term follow up. The aim of the study is to find out the long-term follow up of Whiplash injury and the factors affecting the long-term follow up. Method: It is a retrospective study which was done in Russells Hall Hospital in the west midland in UK. 64 patients were selected in this study. Only 54 patients were replied. An inclusion criterion was Whiplash injury due to RTA in years 1995, 1996 and 1997. Initial examination was performed 5.6 +/ – 4.5 days after trauma, and follow-up examinations 3, 6, 12, and 24 months. Exclusion criteria were any cervical spine bony injury, associate head injury and poly-trauma patients. The outcome measures used for assessment are SF36, Whiplash Disability Questionnaire score WDQS, and questions to cover their present symptoms, work circumstances before and after the injury, current and previous treatment. Results: In our study we found that the time it takes for the patient’s symptoms to resolve varies, it took less than 6 weeks in 4 patients, between 6 weeks to 3 months in 10 patients, between 6 months to 1 year in 15 patients and more than one year in 3 patients. The average follow up time was 10.3 years. Our results did show these figures: 22 patients were still symptomatic 10 years after injury, 18 still complaining of pins &
needles, 13 still having frontal headache and 7 having occipital headache. Headache was one of the symptoms which annoyed Whiplash injury patients. Headaches following Whiplash injuries were occipital, frontal or generalised. Headache was usually of Muscular contraction type, often associated with greater occipital neuralgia. 16 patients still had treatment in the form of pain killers or physiotherapy. The mean WDQS was less than 20 in 38 patients. The mean WDQS in patients with low back pain was 29.23 and for those without back pain were 12.53. In the smokers the mean whiplash score was 32.2. In the non-smokers the Whiplash score was 17.93. The mean WDQS in those who do not drink alcohol was 26.73 and in those who drink alcohol were 16.58. Conclusion: Whiplash injury patients have long term residual symptoms mainly pins &
needles as well as headache and
Introduction: Long-term treatment of chronic muscu-loskeletal pain with opioids often causes a cluster of unpleasant side effects such as constipation,
Introduction and Aims: Caudal and lumbar epidural steroid injections have had a contentious history in the treatment of lumbar radiculopathy. We set out to assess the efficacy of these injections with relation to key discriminators and to assess the safety of these injections. Method: After a literature search highlighted several possible discriminators regarding outcomes for lumbar radiculopathy and surgery we undertook a pilot study to assess the above aims. This took the form of a retrospective telephone interview. When our pilot study reached statistical significance after only 25 patients, we undertook a retrospective study of all 138 patients who had received a caudal or epidural steroid injection for radiculopathy in the last eight years. This took the form of a postal questionnaire, with telephone interview follow-up. Appropriate statistical analysis was performed for the paired and non-paired data collected. Results: Of the 138 patients, 105 could be traced and of these it was possible to compare caudal vs. lumbar epidural in 75. All other comparisons were made on the full available population (105). We showed a statistically significant difference in the following: (i) an overall reduction in pain scores from 7.78 to 5.16 (mean values, difference –2.62, p<
0.0001); (ii) an overall increase in march tolerance from 804m to 1788m (mean values, difference 984m, p,0.0001); (iii) smokers had a higher level of pain overall before, immediately after and longer term than non(N)smokers (mean values smokers vs. non are; before 8.25:7.4, immediately 5.75:4.269, long-term 6.708:5.173, p<
0.01). We found no significant difference between sexes, activity-provoked pain, cough/impulse pain, unemployment due to pain or number of injections received. We had only one serious complication (anaphylactoid reaction) and 10 minor complications including headaches (five), pain at injection site (two),
Incidental durotomy is a relatively common occurrence during spinal surgery. There remains significant concern about this complication despite reports of good associated clinical outcomes. There have been few large clinical series on the subject. Durotomy can cause postural headaches, nausea, vomiting,
Introduction Management of cervical fracture-dislocation varies greatly. When using closed reducition it is not known what are the upper limits of skeletal-traction, the indications and approach of surgery. This study was done to evaluate a stepwise closed reduction protocol using vector principles and define the upper limit of weight tolerated by skeletal traction and manipulation under anaesthesia. Methods This study includes 47 patients of traumatic tetraplegia reporting within three weeks of injury. A sequential protocol was followed using the vector principle for closed reduction by skeletal traction. To begin with, three bricks (18.42 pounds) sustained traction was applied keeping the vector in flexion for five to six hours. This was followed by straightening of the spine and observing realignment. Check x-rays were taken. Acceptable reduction were maintained in extension. If reduciton was unacceptable, weights were added in one brick (6.14 pound) increments and sequential steps repeated. Vector angle in flexion, neutral and extension was easily maintained with bolsters, neck rolls and balancing bar. Manipulation under anaesthesia was tried when this protocol failed. Results Reduction was achieved in 41 of 47 (87.22%) within 24 hours. Maximum weight needed was six bricks (36.84 pounds). All irreducible dislocations showed symptoms of cord stretching when higher weights were applied in terms of pain,
X-linked hypophosphataemic rickets (XLHR) is a disease of impaired bone mineralization characterized by hypophosphataemia caused by renal phosphate wasting. The main clinical manifestations of the disorder are O-shaped legs, X-shaped legs, delayed growth, and bone pain. XLHR is the most common inheritable form of rickets, with an incidence of 1/20 000 in humans. It accounts for approximately 80% of familial cases of hypophosphataemia and serves as the prototype of defective tubular phosphate (PO43+) transport, due to extra renal defects resulting in unregulated The genome DNA samples of all members in the pedigree were extracted from whole blood. We sequenced all exons of the Objectives
Methods