COVID-19 reduced availability of cross-sectional imaging, prompting the need to clinically justify pre-operative computed tomography (CT) in tibial plateau fractures (TPF). The study purpose was to establish to what extent does a CT alter the pre-operative plan in TPF compared to radiographs. There is a current paucity of evidence assessing its impact on surgical planning 50 consecutive TPF with preoperative CT were assessed by 4 consultant surgeons. Anonymised radiographs were assessed defining the column classification, planned setup, approach, and fixation technique. At a 1-month interval, randomised matched CT scans were assessed and the same data collected. A tibial plateau disruption score (TPDS) was derived for all 4 quadrants (no injury=0,split=1,split/depression=2 and depression=3). Radiograph and CT TPDS were assessed using an unpaired T-test.Abstract
INTRODUCTION
METHODOLOGY
At our district general hospital in the southwest of England, around 694 total knee replacements (TKR) are performed annually. Since spring 2013 we have been using an enhanced recovery protocol for all TKR patients, yet we have neither assessed compliance with the protocol nor whether its implementation has made a discernible and measurable difference to the delivery of care in this patient population. Enhanced recovery after surgery (ERAS) protocols are multi-modal care pathways designed to aid recovery. They are based on best evidence and promote a multi-disciplinary approach which standardises care and encompasses nutrition, analgesia and early mobilisation throughout the pre, intra and postoperative phases of an inpatient stay. ERAS has been found to reduce length of stay (LOS), readmission rates and analgesic requirements following surgery.1, 2, 3 Additionally, they have been shown to improve range of knee movement following TKR and improve mobility, patient satisfaction whilst reducing mortality and morbidity.4, 5, 6 With these benefits in mind, we sought to investigate how well our trauma and orthopaedic department was complying with a local ERAS protocol and whether we could replicate the benefits seen within the literature. Following approval from our local audit office in September 2015 we generated a patient list of elective TKR patients under the same surgeon before and after the implementation of the ERAS protocol. Using discharge summaries and patient notes we extracted data for 39 patients operated on prior to the ERAS implementation between January 2011 and December 2012 and 27 patients following its introduction between January 2014 and September 2015. Data collected included length of stay, time to discharge from inpatient physiotherapy and use of analgesia and antiemetics. Alongside this we audited the compliance with all facets of the local ERAS protocol. There was no statistically significant difference between the 2 groups in terms of demographics or pre-operative morbidity. Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all 4 suggested analgesics within the ERAS group. Length of stay (LOS) was significantly reduced by 0.5 days per patient (p value < 0.4). Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia, which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all suggested analgesics within the ERAS group. In terms of LOS, we found a statistically significant difference between the pre-ERAS and ERAS group of 0.5 days per patient. Within the context of our DGH, a 0.5 day reduction in LOS translates to around 350 bed days per year and a potential saving of GBP 105,000 (EUR 132,000) making this a clinically significant finding.
The diagnosis of periprosthetic joint infection may be difficult with patients presenting months or years after initial surgery with surgery-associated or haematogenously spread bacteria. Synovasure™ is a new point of care assay that measures alpha defensin produced by activated leucocytes in joints; it is licensed for the diagnosis of periprosthetic joint infections. We sought to include alpha defensin testing in a testing algorithm to improve the diagnosis of periprosthetic joint infection. An algorithm for testing patients with suspected periprosthetic joint infection was developed and agreed among knee surgeons in Gloucestershire, UK. Data was prospectively collected on all tests performed along with information on how the results of the alpha defensin test altered patient management. A sample of joint fluid was taken using aseptic technique in theatre and tested for alpha defensin production at the point of care. Samples were then referred for standard culture and selected samples for 16SrRNA PCR. 12 patients were assayed for alpha defensin in periprosthetic joint fluid during 2015. 7 patients were female, 5 male and ages ranged 64–86 years. 10 patients had a negative point of care alpha defensin test. Only 2 of these patients also had a leukeocyte esterase (LE) test performed and these were negative. The culture results from all samples were negative for both direct and enrichment cultures. 3 samples also had 16SrRNA PCR performed and these were negative. 2 patient samples tested positive for alpha defensin. LE tests were not performed. Both samples were culture negative on direct and enrichment culture however both samples were also referred for 16SrRNA PCR which detected DNA compatible with Staphylococcus caprae/capitis/ saccharolyticus/epidermidis from 1 patient and DNA with homology to Streptococcus gallolyticus/equinusI for the other. Alpha defensin testing improved the diagnosis of prosthetic joint infection. A positive alpha defensin test may be used to select patients for whom 16SrRNA PCR testing is useful in order to maximise the potential for pre-revision infection diagnosis and the planning of appropriate adjuncts such as antibiotic laden cement or calcium sulphate beads. Negative alpha defensin tests on aspirated joint fluid may avoid the need for arthroscopy and biopsy and allow planning for single stage revision surgery without concern for infection.
