Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author. One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods. Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era.
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
Introduction. Enhanced Recovery After Surgery (ERAS) is a multi-disciplinary approach for establishing procedure–specific, evidence-based perioperative protocols to optimize patient outcomes.
Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either
Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery.
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. METHODS. We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS. Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs 4.4, p<0.001), CCI was significantly lower (12.3 vs 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced with ERAS-outpatient care (9.3 vs 26.5 MME, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner after ERAS-outpatient surgery (p<0.001), but PROMs were similar between groups at the last follow-up (p> 0.188). Patients were more satisfied with hospital stay, pain management, functional recovery, wound management, and overall experience of the ERAS-outpatient pathway and recommended it significantly more (p <0.002). DISCUSSION. Most studies comparing outpatient to inpatient programs conclude that outpatient surgeries did not increase complication or readmission rates, and, overall, were not inferior. We found that compared to std-inpatient practice, ERAS-outpatient program reduced complications by half while not resulting in more unplanned episodes of care. Moreover, it resulted in similar pain relief with fewer opioids, faster early functional recovery and higher satisfaction. Patients were significantly more inclined to recommend the ERAS-outpatient pathway after having personally experienced both outpatient and inpatient protocols. These finding are likely multifactorial and linked to the specific
Introduction. Total hip arthroplasty (THA) dislocation has been associated with different risk factors. The main difficulty in analysing dislocation is its low rate of incidence, necessitating large series for study. We assessed factors related with patients, implant characteristics, and quality of the hip reconstruction to better identify their influence on the THA dislocation rate. Material and Methods. Dislocations in 2,732 THAs performed between 2001 and 2016 were assessed with regard to factors related with the patient (gender, age, preoperative diagnosis, lumbar pathology); the implant (femoral head size, bearing surface, stem offset, femoral head/neck ratio); and the surgical technique (approach, cup and stem position, and abductor mechanism reconstruction). Regression analysis was used for different risk factors and Kaplan-Meier for survival analysis. Results. After