Aims

Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems.

The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is a validated patient reported outcome tool for paediatric foot and ankle conditions. It includes three domains with a maximum score of 100: physical, school and play, and emotional. The purpose of this cross-sectional study is to examine the differences between self-reported child and parent responses of different age groups, genders, and child-parent combinations. During a ten-month period, paediatric patients aged eight to 16 years and their parents completed the OxAFQ-C during routine clinic visits, providing a total 116 child-parent questionnaire dyads. Demographics and diagnostic information was obtained through medical record review. Parent and child responses in each domain were compared for concordance and for effect of demographic variables on the results. Means and standard deviations for parent and child questionnaires for each domain were reported and compared using a two-sample Wilcoxon rank-sum test. A multivariate regression model was used to assess the correlation between demographic characteristics with domain scores. Absolute agreement between patient and parent questionnaires was assessed using intra-class correlation coefficients (ICC) with a two-way random effects model. Seventy patients (60.3%) were female and 46 (39.7%) were male, the majority of parent respondents were mothers (85.3%), followed by fathers (11.2%). Mean patient age was 12.4 (± 2.2) years. Higher scores were reported by the child in every domain, though only the emotional domain score showed statistical significance (p = 0.024) between the parent scores. Male children scored significantly higher than females in school and play domain, (mean 82.38 vs 71.13, p = 0.037) and in the emotional domain (means 90.89 vs79.10, p = 0.002). Parents of males scored significantly higher than parents of females only in the emotional domain (means 86.95 vs 72.67, p = 0.001). Children younger than 13 years old scored significantly higher than older children in the emotional domain (p = 0.004). Child and parent responses for the OxAFQ-C are statistically concordant in the physical and school and play domains. Though children consistently scored themselves higher than their parents did in all domains, only differences in responses for the emotional domain were significant. The level of agreement between parent and child increases with in patients over 13 years of age. Both females and parents of females report lower scores than males and their male parents. Though the use of OxAFQ-C is supported and confirms parent perception of their child's foot and ankle condition is accurate, further research is needed to better understand gender and age differences on response concordance

Patient controlled analgesia (PCA) is commonly used after TKR. Prolonged use of PCA may however have a negative impact on patients delaying their rehabilitation and therefore discharge. We aimed to evaluate the effect of the duration of PCA on the hospital length of stay (LOS) in patients who undergo TKR. We reviewed the casenotes of all patients who underwent a primary TKR in two South Australian teaching hospitals between 2006 and 2007. After excluding patients whose LOS was determined by placement issues and patients who developed intra-hospital post-operative complications, a number of 345 patients were included in this study. Data collected included: age, gender, ASA grade, regional blocks used, duration of postoperative PCA (< 24 hours, 24-48 hours, > 48 hours) and hospital LOS. Using SAS Version 9.2 statistical analysis software the data was analysed using univariate and multivariate Poisson regression models. Risk ratios, confidence intervals and P values were calculated. Univariate regression models showed that there was a significant difference in length of stay between the three PCA groups (p < 0.0001). Post hoc tests revealed that the length of stay was longer in the 24 to 48 hours and > 48 hours groups compared to the < 24 hours group (p < 0.0001). There was also a significant difference in hospital LOS between males and females (p = 0.0049) with females expected to stay on average 9.7% longer (risk ratio = 1.097, 95% CI 1.028, 1.169). Patients in the ASA categories (1 and 2) recorded shorter lengths of stay than patients in the ASA categories (3 and 4) (p < 0.0001). Also patients treated at one hospital had longer LOS than the patients treated at the other hospital (risk ratio = 1.122, p = 0.0001). There was no evidence for a relationship between the patients' ages, and use or type of regional block used and the hospital LOS. Results from the multivariate regression models showed that each of the four variables found to influence LOS significantly, did so independent of the other variables. Therefore, duration of PCA, gender, ASA and hospital were all independent predictors of hospital LOS after primary TKR. Longer administration of PCA, higher ASA grades and female gender are associated with longer hospital LOS after TKR. Reducing postoperative PCA, as well as improving ASA grading, could reduce LOS in these patients. A multimodal pain management strategy that shortens PCA use could reduce hospital LOS and costs after TKR

Our study is still in progress. The results mentioned in the abstract are preliminary results. The final results will be provided at the time of presentation. Over the past decade, the widespread availability of high-resolution ultrasonography coupled with advances in regional anaesthesia have popularised peripheral nerve blocks for anterior cruciate ligament reconstructions (ACLRs). The aim of this study is to investigate whether the femoral nerve block (FNB) administered at the time of ACLR has any long-term impact on the quadriceps strength as compared to patients who did not receive a FNB. This is a retrospective study. Four hundred charts of patients who underwent ACLR at our institution and had subsequent Biodex testing (an isokinetic rehabilitation test that provides objective information about muscle strength deficits and imbalances of the operated leg compared to the non-operated leg) from 2004 to 2015 were reviewed. Patients who had prior ipsilateral knee surgery, multi-ligament knee injury or at extreme ages were excluded from the study. The following baseline patient characteristics was recorded for each reviewed chart: age, sex, medical comorbidities, the date of the injury, date of the surgery, surgery technical notes and associated procedures, the surgeon, the hospital were the patient was operated, the Biodex test date and the Biodex test results. Data extraction assessed any association between the ACLR patients' who received FNB with the results of the Biodex test after completing the rehabilitation protocol. Descriptive statistics were used to compare the type of anaesthesia, mode of pain control and the results of the Biodex tests between patients grouped by the mode of anaesthesia used at the time of surgery (FNB versus no FNB). A multivariate regression model then compared quadriceps strength (inferred by Biodex test results) between groups while controlling for baseline differences between groups. Fifty five percent of the ACLR patients received FNB compared to 45% that did not receive FNB over the last 11 years of performing ACLRs (2004–2015) at our institute. Fifty percent of the patients that received FNB failed to achieve more than or equal to 80% quadriceps strength (compared to the contralateral non-operated leg) at 6 months on Biodex test. On the other hand, only 20% of the non-FNB group failed to achieve more than or equal to 80% quadriceps strength. This study lead us to think that ACLR patients that received FNB are significantly weaker in quadriceps strength at 6 months post ACLR in comparison to non-FNB ACLR patients. This finding subsequently might affect the time needed to return to sports and might indicate a considerable clinical consequence of the FNB on ACL-reconstruction patients

Aim. Whether laminar airflow (LAF) in the operating room (OR) is effective for decreasing periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant yet controversial issue. This study investigated the association between operating room ventilation systems and the risk of PJI in TJA patients. Method. We performed a retrospective observational study on consecutive patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 2013-September 2017 in two surgical facilities within a single institution, with a minimum 1-year follow-up. All procedures were performed by five board-certified arthroplasty surgeons. The operating rooms at the facilities were equipped with LAF and turbulent ventilation systems, respectively. Patient characteristics were extracted from clinical records. PJI was defined according to Musculoskeletal Infection Society criteria within 1-year of the index arthroplasty. A multivariate logistic regression model was performed to explore the association between LAF and risk of 1-year PJI, and then a sensitivity analysis using propensity score matching (PSM) was performed to further validate the findings. Results. A total of 6,972 patients (2,797 TKA, 4,175 THA) were included. The incidence of PJI within 1 year for patients from the facility without laminar flow was similar at 0·4% to that of patients from the facility with laminar flow at 0·5%. In the multivariate logistic regression analysis, after all confounding factors were taken into account, the use of LAF was not significantly associated with reduction of the risk of PJI. After propensity score matching, there was no significant difference in the incidence of PJI within 1 year for patients between the two sites. Conclusions. The use of LAF in the operating room was not associated with a reduced incidence of PJI following primary TJA. With an appropriate perioperative protocol for infection prevention, LAF does not seem to play a protective role in PJI prevention

Aim. Infection is one of the worst complications following total joint arthroplasty, which is often associated with significant morbidity and increased medical costs. Although Gram–positive bacteria remains the most prevalent causative agents, an increase in prosthetic joint infections (PJI) due to gram-negative bacteria (GNB) has been reported. Additionally, the emergence of multidrug resistant resistance (MDR) in GNB impacts the therapeutic options and may increase the rate of treatment failure and drug toxicity adverse effects due the prescription of harmful and toxics antimicrobial schemes. The purpose of the present study was to describe the predisposing factors associated to PJI caused by MDR-GNB in a specialized orthopedic reference hospital in Brazil from 2014 through 2018. Method. Retrospective case-control analysis of patients treated for MDR-GNB PJI over a four-year period (2014–2018). Data were collected from medical, surgical and laboratory records. PJI were defined according the criteria of MSIS. MDR was defined as non-susceptibility to at least one agent in three or more antimicrobial categories. Patients with prosthetic infection with at least two positive tissue cultures for MDR-GNB were selected. Univariate and multivariate logistic regression models were used to determine the independent risk factors associated with MDR-GNB PJI. Controls: patients with PJI with at least two positive tissue culture for non MDR- GNB. Results. A total of 104 patients were selected, 59 patients in the MDR-GNB PJI group and 44 in the control. Patients with MDR-GNB PJI were elderly (mean age of 68.36), distribution among sex was similar (49.2% female and 50.8% male) and 72.3% had one or more comorbidities. Most frequently identified comorbidities were diabetes (10.2%), malnutrition (5.5%), hypertension (4.7 %) and obesity (3.9%). Hip replacement accounted for 91.5% of the cases and 59.3% were revision arthroplasty. The mean time between the placement of the prothesis and the onset of PJI signs and symptoms was 438 days. In the univariate regression, the significant risk factors for MDR-GNB PJI were revision arthroplasty, alcoholism, nonelective arthroplasty, prior antimicrobial use, presence of concomitant infection and blood transfusion. However, in the multivariate analysis, prior use of antimicrobials (OR 9.31, CI95% 3.02–28.64) and the nonelective arthroplasty (OR 6.29, CI95% 1.75–22.6) remained as independent risk factors for MDR-GNB PJI. Conclusions. Previous use of antimicrobial and nonelective arthroplasty are important risk factors for PJI by GNB MDR

Aim. Cutibacterium acnes is a significant cause of late-onset spinal implant infection (SII). In addition, usual preoperative prophylactic measures may be insufficient to prevent C. acnes operating site colonisation and infection, as demonstrated for prosthetic shoulder surgery. However, little information is available regarding risk factors for SII due to this microorganism. The aims of this study were to determine the characteristics of and risk factors for C. acnes SII. Method. we conducted a retrospective unmatched case-control study including all adult patients treated for mono and polymicrobial C. acnes SII during 2010–2015. Controls were randomly selected among patients diagnosed with SII due to other microorganisms during the same period. Results. Fifty-nine patients with C. acnes SII were compared with 59 controls. There was no difference in sex distribution (39% vs 53% men). Patients with C. acnes SII were younger (median age 42 vs. 65, p< 0.001), thinner (median body mass index (BMI) 21 vs. 25 kg/m. 2. , p< 0.001), and presented a better health status (ASA score≤ 2, 83% vs. 65%, p= 0.015; and presence of immunosuppression, 3% vs. 27%, p= 0.002). Patients with C. acnes SII were more likely to experience delayed/late infections (i.e. diagnosed >3 months post-instrumentation, 66% vs. 22%, p< 0.001) and to be instrumented for scoliosis (83% vs. 27%, p< 0.001) with an extended osteosynthesis (median number of fused vertebrae 12 vs. 5, p< 0.001). However, 20 C. acnes SII (34%) developed early (≤3 months) after instrumentation. The clinical presentation was significantly more indolent in the C. acnes group (presence of fever, 27% vs. 61%, p= 0.001; wound inflammation 39% vs. 61%, p< 0.001 and median C-reactive protein level 38 vs. 146 mg/L). Mixed C. acnes SII were diagnosed on 24 occasions (41%), 22 of which involving both C. acnes and staphylococcal strains. In the multivariate logistic regression model, factors independently associated with the development of SII involving C. acnes were age less than 65 (adjusted odds ratio [aOR] 7.13, 95% CI [2.44–24.4], p= 0.001), BMI< 22kg/m. 2. (aOR 3.71 [1.34–10.7], p= 0.012) and a number of fused vertebrae >10 (aOR 3.90 IC 95% [1.51–10.4], p= 0.005). Conclusions. There were significant differences between SII involving C. acnes and those involving other microorganisms. We identified a specific profile of patients at increased risk of developing C. acnes SII. These findings could contribute to improve both the prevention and treatment of such infections

Over the last decade, there has been a growing body of level I evidence supporting non-operative management (focused on early range of motion and weight bearing) of acute Achilles tendon ruptures. Despite this emerging evidence, there have been very few studies evaluating its uptake. Our primary objective was to determine whether the findings from a landmark Canadian trial assessing the optimal management strategy for acute Achilles tendon ruptures influenced the practice patterns of orthopaedic surgeons in Ontario, Canada over a 12-year time period. As a second objective we examined whether patient and provider predictors of surgical repair utilisation differed before and after dissemination of the landmark trial results. Using provincial health administrative databases, we identified Ontario residents 18 years of age and older with an acute Achilles tendon rupture from April 2002 to March 2014. The proportion of surgically repaired ruptures was calculated for each calendar quarter and year. A time-series analysis using an interventional autoregressive integrated moving average (ARIMA) model was used to determine whether changes in the proportion of surgically repaired ruptures were chronologically related to the dissemination of results from a landmark Canadian trial by Willits et al. (first quarter, 2009). Spline regression was then used to independently identify critical time-points of change in the surgical repair rate to confirm our findings. A multivariate logistic regression model was used to assess for differences in patient and provider predictors of surgical repair utilisation before and after the landmark trial. From the second quarter of 2002 to the first quarter of 2010 the surgical repair rate remained constant at ∼21%, however, by the first quarter of 2014 it fell to 6.5%. A statistically significant decrease in the rate of surgical repair (P<0.001) was observed after the results from a landmark Canadian trial were presented at a major North American conference (February 2009). Both teaching and non-teaching hospitals demonstrated a decline in the surgical repair rate over the study period, however, only the decrease seen at non-teaching hospitals was found to be significantly associated with the dissemination of landmark trial results (P<0.001). All other predictors of surgical repair utilisation remained unchanged in the before-and-after analysis with the exception of patients 30 years of age and younger having a higher odds of undergoing surgical repair after the trial when compared to those 51 years of age and older. The current study demonstrates that large, well-designed randomised trials, such as the one conducted by Willits et al. can significantly change the practice patterns of orthopaedic surgeons. Moreover, the decline in surgical repair rate observed at both teaching and non-teaching hospitals suggests both academic and non-academic surgeons readily incorporate high quality evidence in to their practice

Background. Conflicting results about the impact of blood transfusions on outcomes after total knee arthroplasty (TKA) have been reported. We hypothesized that transfusions would be associated with greater readmission and complication rates after primary TKA. Methods. We conducted a retrospective cohort study of the 100% 2008 Medicare Provider Analysis and Review database, and identified primary THA patients by ICD9 codes and excluded fractures/ER admissions to select for elective cases. Patients who received a perioperative blood transfusion (6,951 patients) were compared to a control group who did not receive transfusion (332,762 patients). Descriptive statistics of age, sex, race, diagnosis for surgery, Elixhauser comorbidities, mortality (inpatient, 30, 60, and 90 days and 2 years), readmissions (30, 60, and 90 days), complications (medical and surgical at 30 and 90 days), and revision at 2 years were assessed for both groups. Continuous variables were compared with Student's T-test and categorical variables with chi-square test. Multivariate logistic regression models were constructed to assess the association of transfusion with readmissions, complications, and revisions. Statistical significance was set at p < 0.01. Results. Patients who received a transfusion were older (mean 74.4 vs. 72.6, p<0.0001), more likely to be male (75% vs. 66%, p<0.0001), and had a higher Elixhauser comorbidity count (2.0 vs. 1.85, p<0.0001). Transfused patients had significantly greater readmission rates at 30-days (8.2% vs 5.7%, p<0.0001), 60-days (11.7% vs 8.2%, p<0.0001), and 90-days (14.4% vs 10.4%, p<0.0001). Their overall complication rates at 30 days (2.1% vs 1.4%, p<0.0001) and 90 days (3.2% vs 2.1%, p<0.0001) were greater mainly due to greater surgical complications at 30 days (1.4% vs 0.9%, p<0.0001) and 90 days (2.1% vs 1.3%, p<0.0001). Patients who received a transfusion had significantly higher mortality rates at 2-years (2.2% vs. 1.4%, p<0.0001). Two years after discharge, transfused patients had no difference in revision rates (2.4% vs 2.4%, p=0.8805). Multivariate regression found that transfusion was the third most important factor for surgical complications at 30-days (OR: 1.6, 95% CI: 1.3 to 2.0) and an independent risk factor for readmissions at 60-days (OR: 1.4, 95% CI: 1.3 to 1.5). At 2-years, transfusion was independently associated with mortality (OR: 1.4, 95% CI: 1.2 to 1.7), but not revision (OR: 1.1, 95% CI: 0.9 to 1.3). Conclusion. Primary TKA patients who were transfused had an independently higher risk for surgical complications and readmissions at 30 and 90 days, and mortality within 2 years. Transfusion, however, did not impact revision rates. A restrictive transfusion threshold should be considered for patients undergoing TKA

Background. We switched our antibiotic prophylaxis for elective hip and knee surgery from cefuroxime to flucloxacillin with single dose gentamicin in order to reduce the incidence of C. Diff diarrhoea. More patients subsequently appeared to develop acute kidney injury (AKI). Methods. During a twelve month period we examined the incidence of AKI sequentially in 198 patients undergoing elective hip or knee surgery: cefuroxime (n = 48); high dose flucloxacillin (median 8g) (n = 52); low dose flucloxacillin (median 4g) (n = 46); and cefuroxime again (n = 52). Results. There were no statistically significant differences between the four groups by chi-square tests for age, gender, nature of operation (hip or knee surgery), American Society of Anaesthesia (ASA) grade, mode of anaesthesia (spinal ± general anaesthetic v GA), baseline serum creatinine, pre-operative co-morbidity (hypertension, diabetes), pre-operative medication (NSAIDs, ACEI/ARBs or betablockers) and post-operative hypotension. Patients receiving high dose flucloxacillin required more vasopressors during surgery (p = 0.02 by Kruskal-Wallis test). The proportion of patients in each antibiotic group with any form of AKI by RIFLE criteria was: first cefuroxime group (8%), high dose flucloxacillin (52%), low dose flucloxacillin (22%), second cefuroxime (14%) (p < 0.0001). Odds ratios (OR) for AKI derived from a multivariate logistic regression model and arbitrarily assigning an OR of 1 to first cefuroxime group, were: high dose flucloxacillin 14.5 (95% CI, 4.2–49.7); low dose flucloxacillin 3.0(0.8–10.8); cefuroxime again 2.0(0.5–7.7). Three patients required temporary haemodialysis. Biopsies in two of these showed acute tubulo-interstitial nephritis. All three patients belonged to the high dose flucloxacillin group. None of the patients developed C Diff diarrhoea. Summary. We have shown a strong association between high dose flucloxacillin with single dose gentamicin prophylaxis and subsequent development of AKI which was not confounded by any of the co-variates we measured

Aims

Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty.