Aims

Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture.

Hyponatraemia is a potentially preventable post-operative complication following hip arthroplasty. There is a paucity of literature reporting its incidence and guidelines for prevention - unlike AKI which has been prioritised to great success. Hyponatraemia is now rife in elective orthopaedics causing multiple symptoms that delay ambulation and increase the length of hospital stay. We aim to assess the incidence of hyponatraemia and AKI as a benchmark following elective primary total hip arthroplasty (THA), as well as identify patients most at risk in a high volume arthroplasty centre.

Between April 2018 and September 2018 all primary THA surgeries performed in one hospital were retrospectively reviewed. Pre-operative and 1 day post operative bloods were analysed. Patients included had normal pre-operative sodium.

A total of 221 patients underwent THA. The mean age was 73.6 and ASA 2.1. No patients had a recorded AKI, however 42% of patients had a new post operative hyponatraemia. Of the hyponatraemia cases, 75% were mild, 18% were moderate, and 7% were severe. There was correlation between increased age and increased severity of hyponatraemia. The mean age of patients with mild hyponatraemia was 72.1, moderate was 77.7, and severe was 78.8. An association between ASA and severity of hyponatraemia was noted. In patients who had an ASA of 4 and hyponatraemia, 66% were moderate or severe, ASA 3 was 25%, ASA 2 was 24% and ASA 1 was 0%. The patients who had severe hyponatraemia received on average 3.5L fluid input perioperatively.

Rates of post op hyponatraemia are significantly higher than AKI in primary THA. Severity of hyponatraemia increases with age and ASA. Due to its negative outcomes on recovery the high levels of hyponatraemia are worrying. We have identified which patient cohorts are more at risk and recommend more care should be taken in their perioperative fluid balance. It may be beneficial to consider successful AKI prevention and management campaigns and apply them to the prevention of hyponatraemia following hip arthroplasty.

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, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

The June 2023 Foot & Ankle Roundup³⁶⁰ looks at: Nail versus plate fixation for ankle fractures; Outcomes of first ray amputation in diabetic patients; Vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus; Elderly patients with ankle fracture: the case for early weight-bearing; Active treatment for Frieberg’s disease: does it work?; Survival of ankle arthroplasty; Complications following ankle arthroscopy.

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction. Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning. We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance. Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension. Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital

The February 2023 Spine Roundup³⁶⁰ looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study.

Aims

Routinely collected patient-reported outcome measures (PROMs) have been useful to quantify and quality-assess provision of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in the UK for the past decade. This study aimed to explore whether the outcome following primary THA and TKA had improved over the past seven years.

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.

Aims

Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre.

INTRODUCTION

The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients' satisfaction.

Aims

Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes.

Aims

The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.

Introduction. Enhanced Recovery After Surgery (ERAS) is a multi-disciplinary approach for establishing procedure–specific, evidence-based perioperative protocols to optimize patient outcomes. ERAS evidence is predominantly for non-orthopaedic procedures. We review the impact of ERAS protocol implementation on total joint arthroplasty (TJA) outcomes at our institution. Methods. All primary total hip and knee arthroplasties performed one year before and after ERAS implementation were identified by current procedural terminology code. Length of stay (LOS), disposition, readmission and opioid usage were analyzed before and after ERAS implementation and statistically analyzed with student t-test and chi-square test. Results. 2105 total patients were identified (967 THA, 494 pre-ERAS and 473 post-ERAS;1138 TKA, 575 pre-ERAS and 563 post-ERAS). TKA. After ERAS implementation, opioid consumption decreased for hospital day one (45.5MME to 36.2MME; p=0.000) and overall hospitalization (101.9MME to 83.9MME; p =0.000). Average LOS decreased (73.28hrs to 66.44hrs; p=0.000), blood transfusion rate trended down (3.3% to 1.95%; p=0.155), and disposition to home over skilled nursing facility increased (57.8% to 71.6%; p=0.000). Unplanned return-to-hospital encounters were unchanged (13.22% to 12.79%; p=0.8504). 30-day and 90-day readmission rates decreased (7.30% to 3.02%; p=0.0020 and 8.5% to 4.8%; p=0.0185, respectively). THA. After ERAS implementation, opioid consumption decreased for hospital day one (49.5MME to 35.4MME; p=0.000) and overall hospitalization (79.5MME to 59.5MME; p=0.000). Average LOS decreased (57.84hrs to 51.87hrs; p=0.011), blood transfusion rate was unchanged (4.25% to 3.81%; p=0.725), and disposition to home over skilled nursing facility increased (80.4% to 82.5%; p= 0.022). Unplanned return-to-hospital encounters were unchanged (8.51% to 8.88%; p=0.8486). Readmission trended up during postoperative days 0–30 and trended down during postoperative days 31–90. (1.42% to 2.96%; p=0.1074) and (1.21% to 0.85%; p=0.5748), respectively. Conclusion. ERAS protocols reduce postoperative opioid consumption, decrease hospital LOS, and increase patient disposition to home without adversely affecting short-term readmission rates

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.

Introduction. Postoperative nausea and vomiting (PONV) is a common occurrence following total joint arthroplasty, and can result in patient discomfort, delayed discharge, and decreased patient satisfaction. Carbohydrate loading as part of the Enhanced Recovery after Surgery (ERAS) protocol has gained popularity, and has been shown to minimize postoperative nausea, vomiting, pain, and lead to accelerated recovery and better overall outcome following abdominal surgery. This study aims to investigate the effects of preoperative carbohydrate-rich drinks on PONV following primary total knee arthroplasty (TKA). Methods. Patients undergoing primary TKA at one institution were enrolled randomly assigned to one of three groups: Group 1 received preoperative carbohydrate-rich drink, Group 2 received placebo water drink of similar appearance and taste, and Group 3 did not receive a drink (control). All healthcare personnel and patients (group 1 and 2) were blinded to group allocation. We compared rate of postoperative nausea, vomiting, length of stay (LOS), and opiate consumption (morphine equivalents, meq). We also reviewed visual analog scale (VAS) pain scores and serum glucose at 0–4 hours, 4–12 hours, and 12–24 hours postoperatively. Results. 229 eligible patients were enrolled and randomized. 79 patients were later excluded due to reasons precluding appropriate participation. 150 patients were included for final analysis, with 50 patients in Group 1, 48 patients in Group 2, and 52 patients in Group 3. The demographics and comorbid conditions known to increase risk of nausea and vomiting were similar between the groups. Rate of vomiting was not statistically significant across groups; group 1 (6%, 3/50), group 2 (13%, 6/48), group 3 (8%, 4/52), p=0.51. Rate of requiring antiemetic medication in group 1 (30%, 15/50) did not differ significantly from group 2 (27%, 13/48) and group 3 (40%, 21/52), p=0.32. Average LOS was not different in group 1 (32 hours) compared to group 2 (32.5 hours) and group 3 (32 hours), p=0.79. Average postoperative opiate consumption for group 1 (57.0 meq) was not statistically different from group 2 (61.3) or group 3 (61.0), p=0.91. Pain VAS scores and serum glucose measurements did not differ between groups for all three time periods (p>0.05). There was no difference in reported adverse events between groups. Conclusion. There appears to be no significant difference in PONV, antiemetic requirements, LOS, pain VAS scores, serum glucose measurements, and opiate consumption in patients receiving preoperative carbohydrate-rich drink prior to primary TKA. Preoperative carbohydrate-rich drinks are safe, however, their utility in the setting of arthroplasty does not yet demonstrate clinical benefit. Continued investigation is required. Summary. This is a prospective, randomized, double-blind, placebo-controlled trial investigating the effect of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting following primary total knee arthroplasty. For any figures or tables, please contact authors directly