Enhanced recovery pathways (ERPs) utilise multimodal rehabilitation techniques to reduce post-operative pain and accelerate the rehabilitation process following surgery. Originally described following elective colonic surgery enhanced recovery pathways have gained increasing use following elective hip and knee joint replacement in recent years. Early studies have indicated that enhanced recovery pathways can reduce length of hospital stay, reduce complications and improve cost-effectiveness of joint replacement surgery. Despite this growing evidence base uptake has been slow in certain centres and many surgeons are yet to utilise enhanced recovery pathways in their practice. We look at the process and effects of implementing an enhanced recovery pathway following total hip replacement surgery at a district general hospital in the United Kingdom. A retrospective study was initially undertaken over a four-month period to assess patient demographics, length of stay, time to physiotherapy and complication rates including re-admission within 28 days. Based on national recommendations an enhanced recovery pathway protocol was then implemented for an elective total hip replacement list. Inclusion criteria were elective patients undergoing primary total hip replacement (THR) surgery. The pathway included pre-operative
The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures. The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The
Malnutrition is often associated with the advanced age and can be influenced by physical, mental, social and environmental changes. Hip fracture is a major issue and a prior poor
Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition. 603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³. Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European. This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative
Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including
Neuromuscular scoliosis patients face rates of major complications of up to 49%. Along with pre-operative risk reduction strategies (including
This paper presents the
Purpose. Disc degeneration is known to occur early in adult life, but at present there is no medical treatment to reverse or even retard the problem. Development of medical treatments is complicated by the lack of a validated long term organ culture model in which therapeutic candidates can be studied. The objective of this study was to optimize and validate an organ culture system for intact human intervertebral disc (IVD), which could be used subsequently to determine whether synthetic peptide growth factors can stimulate disc cell metabolism and initiate a repair response. Method. Seventy lumbar IVDs, from 14 individuals, were isolated within 24 h after death. Discs were prepared for organ culture by removing bony endplates but retaining cartilaginous endplates (CEP). Discs were cultured with no external load applied. The effects of glucose and FBS concentrations were evaluated. Dulbeccos Modified Eagle Media (DMEM) was supplemented with glucose, 4.5g/L or 1g/L, referred to as high and low (physiological) glucose, and FBS, 5% or 1%, referred to as high and low FBS, respectively. After a four week culture period, samples were taken across the disc using a 4 mm biopsy punch. Cell viability was analyzed using a live/dead fluorescence assay (Live/Dead, Invitrogen) and visualized by confocal microscopy. CEP discs were also placed in long term culture for four months, and cell viability was assessed. Western bolt analysis for the G1 domain of aggrecan was also performed to assess the effect of
Purpose. Disc degeneration is known to occur early in adult life, but at present there is no medical treatment to reverse or even retard the problem. Development of medical treatments is complicated by the lack of a validated long term organ culture model in which therapeutic candidates can be studied. The objective of this study was to optimize and validate an organ culture system for intact human intervertebral disc (IVD), which could be used subsequently to determine whether synthetic peptide growth factors can stimulate disc cell metabolism and initiate a repair response. Method. Seventy lumbar IVDs, from 14 individuals, were isolated within 24 h after death. Discs were prepared for organ culture by removing bony endplates but retaining cartilaginous endplates (CEP). Discs were cultured with no external load applied. The effects of glucose and FBS concentrations were evaluated. Dulbeccos Modified Eagle Media (DMEM) was supplemented with glucose, 4.5g/L or 1g/L, referred to as high and low (physiological) glucose, and FBS, 5% or 1%, referred to as high and low FBS, respectively. After a four week culture period, samples were taken across the disc using a 4 mm biopsy punch. Cell viability was analyzed using a live/dead fluorescence assay (Live/Dead, Invitrogen) and visualized by confocal microscopy. CEP discs were also placed in long term culture for four months, and cell viability was assessed. Western bolt analysis for the G1 domain of aggrecan was also performed to assess the effect of
Obtaining primary wound healing in total joint arthroplasty (TJA) is essential to a good result. Wound healing disturbances (WHD) can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromise factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphodema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor
The true results of revision total knee arthroplasty (TKA) are not fully understood, for a variety of understandable reasons. But it is has been clear for decades that revision without a diagnosis is likely to fail. The evaluation of the problem TKA should be systematic (follow the same scheme every time) and comprehensive (all possibilities should be considered even if one diagnosis seems obvious). Evaluation begins, as with all of medicine with a list of possible causes: the mechanisms of failure. John Moreland was the first to describe a coherent system which needed only one simple addition to be complete: 1.) Prosthetic joint infection; 2.) Extensor disruption; 3.) Patella and malrotation; 4.) Loose; 5.) Component breakage; 6.) PP fracture; 7.) Poor motion; and 8.) Tibial femoral instability. Evaluation begins with the history, where 10 questions in particular are useful: 1.) What seems to be the problem? 2.) Was the “knee” ever successful after surgery? If there was never pain relief, is the current pain, the same or different? 3.) Standard pain quality questions - Location, duration, frequency, quality, exacerbating, ameliorating. 4.) Swelling? 5.) Stiffness? 6.) Giving way? 7.) Weakness? 8.) Things “just don't feel right”? 9.) Possible sepsis questions - Fever, chills, sources, primary TKA healing. 10.) Mood, social situation?. The physical exam should cover these ten points: 1.) Active extension; 2.) Rising from chair; 3.) Gait: hip, knee alignment, knee instability; 4.) Hip (internal rotation); 5.) Inspection; 6.) Tenderness; 7.) ROM; 8.) Stability (extension and 30–45 degrees flexion; 9.) Sitting on edge of exam table (knee at 90 degrees); and 10.) Step up on low stool (stair). Investigations include: 1.) ESR + CRP; 2.) CBC; 3.) HGB- anemia; 4.) Lymphocytes-
The avascular nature of articular cartilage relies on diffusion pathways to obtain essential nutrients and molecules for cellular activity. Understanding these transport pathways is essential to maintaining and improving the health of articular cartilage and ultimately synovial joints. Several studies have shown that joint articulation is associated with fluid and solute uptake although it remains unclear what role sliding motion independently plays. This study investigates the role of sliding with a non-stationary contact area on the uptake of small molecular weight tracers into articular cartilage. Ten-millimeter diameter cartilage-bone plugs were obtained from porcine knee joints and sealed into purpose made diffusion chambers. The chambers were designed to eliminate diffusion from the radial edge and only allow diffusion through the articular surface. The bone side of the chamber was filled with PBS to maintain tissue hydration while the cartilage side was filled with 0.01mg/ml fluorescein sodium salt (FNa) prepared using PBS. Sliding loads with a non-stationary contact area were applied across the articular surface by a custom apparatus using a 4.5 mm diameter spherical indenter. A moving contact area was chosen to represent physiological joint motions. Reciprocal sliding was maintained at a rate of 5 mm/s for 2 and 4 hours. Control samples were subject to passive diffusion for 0, 4, and 88 hours. After diffusion tests, samples were snap frozen and 20 µm cross-sectional cuts were taken perpendicular to the sliding direction. Samples were imaged using a Zeiss AxioImager M2 epifluorescent microscope under 5× magnification with a filter for FNa. Intensity profiles were mapped from the articular surface to the subchondral bone. Unloaded control samples demonstrated minimal solute uptake at 4 hours penetrating less than 5% of the total cartilage depth. By 88 hours solute penetration had reached the subchondral bone although there was minimal accumulation within the cartilage matrix indicated by the relatively low intensity profile values. Samples that had been subjected to reciprocal sliding demonstrated accelerated penetration and solute accumulation compared to unloaded samples. After 1 hour of reciprocal sliding, the solute had reached 40% of the cartilage depth, this increased to approximately 80% at 4 hours, with much higher intensities compared to unloaded controls. Sliding motion plays an important role in the uptake of solutes into the cartilage matrix. Maintaining joint motion both post injury and in the arthritic process is a critical component of cartilage
Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor
Malnutrition is an important consideration during the perioperative period and albumin is the most common laboratory surrogate for
Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immune compromise, steroids, smoking, and poor
Periprosthetic infection involving TKR has been projected to rise as the burden of implanted TKR continues to grow. A study by Kurtz et al. found a significant increase in the annual incidence of TKR infection, 2001 (2.05%) to 2.18% in 2009. Thus, deep prosthetic infection around a TKR remains a significant problem that has not been solved, even as technologies improve and the operation is more commonly performed. The economic hospital cost of periprosthetic TKR infection is approximately $100,000 US for a two-stage removal and reimplantation; by the year 2020, it is estimated that 48,000 of these operations will be necessary. The total annual hospital cost for PJI treatment is expected to be over $1 billion by 2020, and does not include the doctor, pharmacologic, and physical therapy fees. Many factors have been found to be associated with an increased risk of PJI. This lecture will focus upon the peri-, intra-, and post-operative factors that have been found historically to carry an increased or decreased risk of infection. Preoperative factors that have been found to affect the risk of infection include: perioperative administration of intravenous antibiotics, patient
In a recent study, 54.5% of patients reporting to arthroplasty clinics in the US were obese. We performed a recent literature review to determine how obesity impacts outcomes in total hip and knee arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient. Specifically, obese patients have shown increased rates of infection, dislocation, need for revision, wound dehiscence, increased operative time and prolonged hospital stay. Additionally, obese TKA patients have been shown to have increased rates of aseptic loosening, thromboembolic events, wound complications, and cardiopulmonary events. Worsening severity of obesity seems to correlate with worsening outcomes and super obesity (BMI>50) has been identified as an independent risk factor for complications. Patients with BMI>35 have shown to be 6.7 times more likely to develop infection after TKA. Patients with BMI>40 have a 3.35 times higher rate of revision for deep infection than those with BMI<35. The odds ratio for major complications increases dramatically beyond BMI>45. How can we improve outcomes in the obese patient? Preoperative care for the obese patient involves
Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy.Aims
Methods
Periprosthetic joint infection (PJI) is a major complication affecting >1% of all total knee arthroplasties, with compromise in patient function and high rates of morbidity and mortality. There are also major socioeconomic implications. Diagnosis is based on a combination of clinical features, laboratory tests (including serum and articular samples) and diagnostic imaging. Once confirmed, prompt management is required to prevent propagation of the infection and further local damage. Non-operative measures include patient resuscitation, systemic antibiotics, and wound management, but operative intervention is usually required. Definitive surgical management requires open irrigation and debridement of the operative site, with or without exchange arthroplasty in either a single or two-stage approach. In all options, the patient's fitness, comorbidities and willingness for further surgery should be considered, and full intended benefits and complications openly discussed. Late infection almost invariably leads to implant removal but early infections and acute haematogenous infections can be managed with implant retention – the challenge is to retain the original implant, having eradicated infection and restored full function. Debridement with component retention: Open debridement is indicated for acute postoperative infections or acute haematogenous infections with previously well-functioning joints. To proceed with this management option the following criteria must be met: short duration of symptoms - ideally less than 2–3 weeks but up to 6; well-fixed and well-positioned prostheses; healthy surrounding soft tissues. Open debridement is therefore not an appropriate course of management if symptoms have been prolonged – greater than 6 weeks, if there is a poor soft tissue envelope and scarring, or if a revision arthroplasty would be more appropriate due to loosening or malposition of the implant. It is well documented in the literature that there is an inverse relationship between the duration of symptoms and the success of a debridement. It is thought that as the duration of symptoms increases, other factors such as patient comorbidities, soft tissue status and organism virulence play an increasingly important role in determining the outcome. There is a caveat. Based on our learning in the hip, when we see an acute infection where periprosthetic implants are used, it is much easier to use this time-limited opportunity to remove the implants and the associated biofilm and do a single-stage revision instead of just doing a debridement and a change of insert. This will clearly be experience and prosthesis-dependent but if the cementless implant is easy to remove, then it should be explanted. One critical aspect of this procedure is to use one set of instruments and drapes for the debridement and to then implant the new mobile parts and close using fresh drapes and clean instruments. Units that have gained expertise in single-stage revision will find this easier to do. After a debridement, irrigation, and change of insert, patients continue on intravenous antibiotics until appropriate cultures are available. Our multidisciplinary team and infectious disease experts then take over and will dictate antibiotic therapy thereafter. This is typically continued for a minimum of three months. Patients are monitored clinically, serologically, and particularly in relation to
Pathologic fractures about the hip are an uncommon, but increasingly prevalent, clinical scenario encountered by orthopaedic surgeons. These fractures about the hip usually necessitate operative management. Life expectancy must be taken into account in management, but if survivorship is greater than 1 month, operative intervention is indicated. Determination must be made prior to operative management if the lesion is a solitary or metastatic lesion. Imaging of the entire femur is necessary to determine if there are other lesions present. Bone lesions that have a large size, permeative appearance, soft tissue mass, and rapid growth are all characteristics that suggest an aggressive lesion. Biopsy of the lesion in coordination with the operative surgeon should be conducted if the primary tumor is unknown. Metastatic disease is much more common than primary tumors in the adult population. Many metastatic fractures in the intertrochanteric region, and all fractures in the femoral neck and head are an indication for hemiarthroplasty or total hip arthroplasty. Cemented femoral implants are generally indicated. This allows immediate weight bearing in a bone with compromised bone stock, thus reducing the risk of peri-operative fractures. Additionally, patients are often treated with radiation and/or chemotherapy, which may prevent proper osseointegration of an ingrowth femoral component. Highly porous ingrowth shells have been shown to provide reliable and durable fixation even in these situations. Management of a periacetabular pathologic fracture, particularly resulting in a pelvic discontinuity is a particularly challenging situation. Use of a highly porous acetabular component combined with an acetabular cage, a custom acetabular component, a cemented Harrington technique, or a primary acetabular reconstruction cage may be utilised. Patients with neoplastic disease are often at risk for infection and thromboembolic disease both from the disease and treatment. Pre-operative evaluation of
