Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Various studies have demonstrated that the necessity for reversal of Warfarin through the use of Vitamin K (Vit K) in neck of femur fracture patients introduces increased duration of stay and poorer outcomes as measured by operative complications and mortality rate. One reason for this delay may be the time latency between admission and the clinicians decision to investigate the INR. In this study we aim to explore the different causes of latency which contribute to a delay to theatre and ascertain whether point of care testing may negate this. We carried out an audit of a cohort of neck of femur fracture patients between 2012 and 2015. Between September 2011 and September 2013, paper notes of 25 patients who were on warfarin at the time of sustaining a Neck of femur fracture (NOF) was obtained within Addenbrookes hospital archives. An additional 80 patients records from the year 2015 were retrieved from EPIC digital records. Time intervals were recorded as follows (from time of A&E assessment by Medical doctor); Interval to orthopaedic specialist assessment, Interval to first INR order, Interval to first INR result seen by specialist, Interval to first Vit K prescribed, Interval to first Vit K given, Interval to Second INR ordered, Interval to second INR seen by specialist, Interval to operation time (as determined by time of team briefing). Analysis of the time intervals as a proportion of total time elapsed between A&E assessment and Time to theatre was performed. Point of care (POC) testing of INR on admission to A&E was introduced and a symmetrical time period was analysed for the same intervals. The latency generated by time taken for a NOF to be assessed by an orthopaedic specialist occupied 8.60% of the total time, the interval between ordering and recording an INR value accounted for 7.96% of time to theatre, the interval between an INR being recorded and subsequently seen by a clinician accounted for 13.4% of time to theatre, the time between orthopaedic specialist assessment and prescription of Vit K took up 7.83% of the total time and the percentage time between Vit K prescription and administration was 12.3%. The time between the first dose of Vit K prescription and arriving at theatre accounted for 76.1% of latency and the time between viewing a second INR and time to theatre occupied 33% of the total time. Following introduction of POC INR testing, there was a statistically significant decrease in time taken for warfarin reversal and consequently a reduction between time of admission to time to theatres. NOF patients who are on warfarin at time of injury introduces complexity to surgical management and planning for theatre. In our audit we demonstrate that causes of delay are distributed throughout the pathway of care and there are several stages. POC INR testing represents an effective method of reducing this latency and improves patient outcome

Treatment of tibial osteomyelitis can be challenging and lengthy, with numerous complications possible during rehabilitation. We report on the usage of the Taylor Spatial Frame (TSF) for a large cohort of patients, and analyse factors that affect outcomes. Between 2015-2020, 51 patients were treated with TSF for osteomyelitis at a major trauma centre. Demographic, infection and treatment factors of: age, smoking status, diabetes, and BMI, acute (<6 weeks post injury) or chronic (>6 weeks) osteomyelitis, bacteria isolated, time to debridement, therapy/surgery number of TSF, time TSF was in, antibiotic treatment period, time to partial weight bear (PWB) and full weight bear (FWB) prescriptions, were collected. Outcomes of complications and time to union were obtained. Radiological union was achieved at mean 11.0 months. Mean follow up was 24.1 months. Six and three patients were further treated with fusion and amputation respectively. Mean treatment time with TSF was 12.1 months. 78% had some complications, with pin site infection, malunion, and non-union being most prevalent. Univariate factor analysis, multicollinearity diagnostics, then multivariate model construction were performed. Staphylococcus Epidermidis in bone debridement microbiology was significantly negatively associated with pin site infection (OR 0.093, 95% CI 0.011-0.828) and malunion (OR 0.698, 95% CI 0.573-0.849), and enterococcus with non-union (OR 0.775, 95% CI 0.656-0.916), during the treatment period. Time to union was significantly positively associated with time from admission to debridement (p=0.035), time TSF was in (p=0.021), presence of complications (p=0.045), bone loss complication(p=0.037), time to FWB prescription(p=0.001). We have analysed the effectiveness of TSF in the treatment of tibial osteomyelitis, and elucidated important injury, treatment and rehabilitation factors that affect outcome. The negative bacterial-complication cross associations could be due to successful eradication as culture specific antibiotics were used postoperatively. Earlier patient full weight bearing could enhance callous formation leading to faster union

Introduction:. Antimicrobial resistance is an important patient safety issue. Antibiotic Stewardship is one of the key strategies in tackling this problem. We present our data over a two year period from October 2011 to December 2013. Method:. A multidisciplinary, consultant led antibiotic ward round was implemented in October 2011. This involved the consultant orthopaedic surgeon, microbiologist, pharmacist and antibiotic prescription nurse. Data from the meetings was collected prospectively over a 118 week period using a standard data form. The case notes, prescription kardex, laboratory results including microbiology data and clinical information of patients was available at the time of the Ward round. The indications for, choice of antibiotics, duration and further treatment plan were made and a note for the case notes was dictated immediately. Changes to prescriptions were also made at the time. Results:. Over the first 2 years 269 patients were reviewed. We noticed a 22% decrease in the volume of IV antibiotic prescriptions. 35% of antibiotic prescriptions were de-escalated (reducing the dose or narrowing the spectrum), however 9% required escalation. 2% of prescriptions were stopped for being clinically not required any more. There was 48% decrease in costs of IV antibiotics and 30% decrease in total cost of oral and IV antimicrobials. Discussion:. We find that this exercise leads to a clear, documented, more cohesive approach to patients' treatment which improves patient care. It makes the orthopaedic consultant and on call team aware of all patients on antibiotics and the plan for the following week. Conclusion:. Antibiotic Stewardship in our hospital has led to the decrease in the use of antibiotics and reduced costs along with several other soft benefits in patient treatment. Given the rising problem of antibiotic resistance, this key pillar strategy against it should be implemented in all hospitals

Due to working time restrictions a full-shift cross-covering system is commonplace. As more than one surgeon is responsible for trauma admissions in a 24-hour period a complete handover is paramount to ensure continuity of care. The purpose of this audit was to determine whether the introduction of a formal handover/admission form would improve this continuity with regards to prescription of venous thromboembolism (VTE) prophylaxis in hip fracture patients. In Stirling Royal Infirmary chemical VTE prophylaxis for hip fracture patients is 40mg enoxaparin at 6pm unless there is a contraindication. Over a 14-day period we prospectively documented the prescription of VTE prophylaxis and doses missed under the current admissions system. Following this a proforma was introduced that was to be exchanged at handover meetings. The proforma included patients' name/details, admission ward, and tasks to be completed during clerk-in, including VTE prophylaxis prescription. Tasks outstanding at handover had to be documented and completed by the subsequent doctor. Each form was signed and dated by the receiving doctor. We subsequently re-evaluated the prescription of VTE prophylaxis in hip fracture patients. Between 1/12/10-15/12/10, 23 patients were admitted with hip fracture. 12 had appropriate VTE prophylaxis, 6 missed one dose, 4 missed two, and 1 missed three all due to failure of prescription. Following the introduction of the proforma, 12 patients were admitted with hip fractures between 31/12/10-14/1/11. All were prescribed appropriate VTE prophylaxis and missed no doses. 1 patient was on warfarin and had enoxaparin prescribed but withheld until INR< 2.0. After the introduction of a handover form VTE prophylaxis prescription vastly improved. This proforma ensured that all elements of initial management were completed allowing for physician accountability, greater efficacy of handover and continuity of care

Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis. Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Background. Polypharmacy of elderly trauma patients entails further difficulties in addition to the fracture treatment. Impaired renal function, altered metabolism and drugs that are potentially delirious or inhibit ossification, are only a few examples which must be carefully considered for the medication in elderly patients. The aim of this study was to investigate, if medication errors could be prevented by orthogeriatric comanagement compared to conventional trauma treatment. Material and methods. In a superregional traumacenter based on two locations in Munich, all patients ≥ 70 years with proximal femur fracture were consecutively recorded in a period of 3 months. After the end of the treatment the medical records of each patient were analyzed. At the hospital location 1 the treatment was carried out without orthogeriatric comanagement, at the hospital location 2 with this concept (DGU-certified orthogeriatric center). In addition to the basic medication all newly added drugs were recorded as well as changes in the medication plan and also wether treatment was carried out by the geriatrician or the trauma surgeon. Based on the START / STOPP criteria for the medication of geriatric patients, we defined “no-go” drugs with the geriatrician of the orthogeriatric center which should be avoided in the orthogeriatric patient (including benzodiazepines, gyrase inhibitors, NSAID like Ibuprofen with impaired GFR). The statistical analysis was done with the chi-square-test (IBM SPSS Statistics 24). Results and conclusion. A total of 46 patients were included, 37 of them female and 9 male with an average age of 84,5 years (SD±6.8). At the location without a geriatrician (18 patients), a prescription of one or more “no-go” drugs was found in 9 patients, whereas in location 2 (28 patients) only in 3 patients (p=0.003). Besides that, at the location with the geriatrician, a change in the medication was made for 17 patients during their stay in hospital. This shows that with the fixed integration of the geriatrician into the trauma surgical team, errors in the medication of the patients could be significantly more frequent avoided or faster detected and corrected. Although this should not limit the responsibility of the rest of the team, there is no doubt about the importance of the interdisciplinary treatment of elderly trauma patients

Introduction. Perioperative antibiotic prophylaxis use in modern orthopaedic procedures is well established. Studies have shown significant reduction in risk of post-operative infections. However, as effectiveness of these antibiotics is dependent on achieving high serum and tissue concentrations that exceed the minimum inhibitory concentrations of infective organisms for operation duration, the timing of prophylaxis is crucial. Although, optimal timing for administering prophylaxis varies in the literature, 30 to 60 minutes prior to skin incision or inflation of tourniquet is considered best standards. Objectives. To audit our practice of timing of administration of perioperative prophylactic antibiotics in trauma and orthopaedic procedures. Methods. A double-centre prospective analysis was conducted over a period of 2 week (trauma) and 2 months (elective). Centre A involved trauma cases where centre B involved elective Total Knee Arthroplasty cases. Patients were excluded if they were already on regular antibiotics or when prophylaxis was not indicated. Prescription charts and anaesthetic charts were reviewed along with electronic theatre database. Results. A total of 109 patients were included (52 elective and 57 trauma). Only 21% of patients received prophylactic antibiotics within 30 to 60 minutes of knife to skin time or inflation of tourniquet. Two third of patients received prophylaxis earlier than recommended with 28% receiving prophylaxis between 5 to 10 minutes and 33% between 15 to 20 minutes prior to knife to skin time or inflation of tourniquet. Conclusions. Our audit highlights an important deviation from standard best practice. To address this problem we recommend a multidisciplinary team approach including anaesthetic, ward and theatre teams. Level of Evidence. III - Evidence from case, correlation, and comparative studies

Since the establishment of our department a multi-modal approach to thromboprophylaxis that uses aspirin for chemical prophylaxis was adopted. In accordance with the latest national recommendations, our routine chemical prophylaxis following arthroplasty was changed to rivaroxaban in 2012 and then dalteparin in 2013. This study aimed to compare venous thromboembolism (VTE) rates during the use of the aspirin-based protocol used from 2004 to 2011 with recent, rivaroxaban and dalteparin-based guidelines. Outcome data from ISD Scotland was retrieved and radiology reports performed for CT pulmonary angiograms and lower limb doppler ultrasound scans in our institution were assessed to identify cases of VTE following primary hip or knee arthroplasty. The incidence of pulmonary embolism (PE) and proximal deep venous thrombosis (DVT) was calculated for each year and compared using a Chi-squared test. Additionally, the change in extended thromboprophylaxis regimen was surveyed by recording the discharge prescriptions for consecutive arthroplasty patients for March every year. There were 90 radiologically confirmed cases of DVT or PE between 2004 and 2011 (incidence of 0.71%). The DVT/PE rate was subsequently 0.67% in 2012 and 0.69% in 2013, with a further 29 cases identified. This does not represent a significant change in the venous thromboembolism rates and remains below the national incidence of VTE (1.06%). Aspirin alone was used as chemical thromboprophylaxis in 80.8% of patients from 2004 to 2011, 50.9% in 2012, and 12.1% in 2013. The incidence of VTE at our centre remains favourable to national figures, but the modification of thromboprophylaxis guidelines will incur additional financial costs and has not had a significant reduction on the rate of VTE

Low molecular weight heparin (LMWH) is frequently used as thromboprophylaxis after major orthopaedic surgery. Varying levels of non-adherence (5% to 45%) with outpatient LMWH has been reported. Oral direct thrombin inhibitors have been recommended by industry due to ease of administration. We aim to audit the compliance rate with outpatient LMWH treatment following primary total hip arthroplasties (THA) in our district general hospital (DGH). Using the ORMIS computer system, we identified all primary THA performed in Monklands Hospital between July 2011 and August 2012. Patients’ case notes were analysed retrospectively, looking at operating surgeon's postoperative thromboprophylaxis instructions. We then conducted a telephone interview on patients discharged with outpatient LMWH to assess compliance. There were 58 primary THAs performed during the audit period. 33 patients were discharged on outpatient LMWH, whilst 15 patients and 3 patients were discharged on aspirin and warfarin respectively. Seven patients were excluded as their discharge prescriptions were missing. We successfully contacted 20 of the 33 patients discharged with outpatient LMWH. All respondents showed 100% compliance to the full course of treatment. 50% of patients self-administered; 30% were administered by district nurses and 20% by family members. 35% of patients preferred an oral tablet alternative, for its perceived ease of administration. Bruising and skin irritation were the reported problems in some patients, but these did not affect compliance. Contrary to the previous published non-adherence rates, the compliance rate with outpatient LMWH after THA was high in our DGH. The patient counseling, and family/district nurse involvement in may have contributed to this. However, our numbers of patients are low but data collection continues

Objectives

Bisphosphonates (BP) are the first-line treatment for preventing fragility fractures. However, concern regarding their efficacy is growing because bisphosphonate is associated with over-suppression of remodelling and accumulation of microcracks. While dual-energy X-ray absorptiometry (DXA) scanning may show a gain in bone density, the impact of this class of drug on mechanical properties remains unclear. We therefore sought to quantify the mechanical strength of bone treated with BP (oral alendronate), and correlate data with the microarchitecture and density of microcracks in comparison with untreated controls.

Osteoarthritis (OA) is an important cause of pain, disability and economic loss in humans, and is similarly important in the horse. Recent knowledge on post-traumatic OA has suggested opportunities for early intervention, but it is difficult to identify the appropriate time of these interventions. The horse provides two useful mechanisms to answer these questions: 1) extensive experience with clinical OA in horses; and 2) use of a consistently predictable model of OA that can help study early pathobiological events, define targets for therapeutic intervention and then test these putative therapies. This paper summarises the syndromes of clinical OA in horses including pathogenesis, diagnosis and treatment, and details controlled studies of various treatment options using an equine model of clinical OA.