Purpose
Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can ...result. As no standards currently exist, we aimed to develop best practice pain management guidelines.
Methods
A local steering committee (
n
= 16) surveyed 116 North American foot and ankle surgeons to understand the “current state” of practice. A multidisciplinary expert panel (
n
= 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and “current state” survey respondents to create a consensus document using a Delphi process conducted from September to December 2020.
Results
One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively.
Conclusions
Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.
Background:
Although good short-term and midterm outcomes are reported for mini-open rotator cuff repair, few prospective studies have investigated long-term results.
Hypothesis:
Function and ...health-related quality of life (HRQL) outcomes would be maintained 10 years after mini-open rotator cuff repair.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
Patients with a confirmed full-thickness rotator cuff tear who underwent mini-open repair between April 1997 and July 2000 were evaluated preoperatively as well as 1 year and 10 years postoperatively for (1) pain, function, and HRQL using the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff Index (WORC) score; (2) active shoulder range of motion (ROM) using goniometry; and (3) satisfaction by an independent evaluator. Changes in function, HRQL, and ROM over time were analyzed using repeated-measures analysis of variance.
Results:
A total of 84 patients were enrolled, of which 61 (73%) were men; the mean (±SD) age was 53.0 ± 9.9 years. At 10 years, 4 (5%) patients were deceased, and 4 (5%) had symptomatic retears. Fifty-nine (74%) patients were evaluated, composed of 43 (73%) men; 26 (44%) were younger than 60 years. Function and HRQL significantly improved over the course of follow-up (P < .001), primarily within the first postoperative year. At 10 years, the mean ASES score was 90.4 ± 19.4, similar to the 1-year score of 91.1 ± 12.0 (P = .83). The mean WORC score at 10 years was 88.7 ± 17.8, with no change from the 1-year score of 88.4 ± 13.6 (P = .93). This relationship did not change after adjusting for age and tear size. Shoulder ROM was also maintained over 10 years. Flexion ROM improved in the first postoperative year, and this improvement was sustained at 10 years after surgery (P ≥ .30). External rotation ROM was slower to improve postoperatively, and significant improvements were seen between 1 and 10 years (P < .01). Fifty-three patients (90%) were satisfied or very satisfied with their results. Tear size, workers’ compensation board claimant status, sex, and smoking status did not influence HRQL or shoulder ROM (P > .06).
Conclusion:
Postoperative improvements in function and HRQL after mini-open rotator cuff repair were retained at 10 years.
OBJECTIVES:Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a ...matched-series analysis compared outcomes with subjects who underwent delayed wound closure.
DESIGN:Prospective cohort between 2009 and 2013 of subjects undergoing primary closure.
SETTING:Trauma center.
PARTICIPANTS:Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects).
INTERVENTION:Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year.
MAIN OUTCOME MEASUREMENTS:Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture.
RESULTS:Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses n = 68 pairs; (136 subjects), the primary closure cohort had fewer deep infections n = 3 (4%) vs. n = 6 (9%) and nonunions n = 9 (13%) vs. n = 19 (29%) than the delayed closure cohort (P < 0.001).
CONCLUSIONS:Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
ObjectiveThe Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs ...by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada. DesignThe study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017-Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor. ResultsOf the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain. ConclusionThe implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.
Comprehensive and timely rehabilitation for total joint arthroplasty (TJA) is needed to maximize recovery from this elective surgical procedure for hip and knee arthritis. Administrative data do not ...capture the variation of treatment for rehabilitation across the continuum of care for TJA, so we conducted a survey for physiotherapists to report practice for TJA across the continuum of care. The primary objective was to describe the reported practice of physiotherapy for TJA across the continuum of care within the context of a provincial TJA clinical pathway and highlight possible gaps in care.
A cross-sectional on-line survey was accessible to licensed physiotherapists in Alberta, Canada for 11 weeks. Physiotherapists who treated at least five patients with TJA annually were asked to complete the survey. The survey consisted of 58 questions grouped into pre-operative, acute care and post-acute rehabilitation. Variation of practice was described in terms of number, duration and type of visits along with goals of care and program delivery methods.
Of the 80 respondents, 26 (33 %) stated they worked in small centres or rural settings in Alberta with the remaining respondents working in two large urban sites. The primary treatment goal differed for each phase across the continuum of care in that pre-operative phase was directed at improving muscle strength, functional activities were commonly reported for acute care, and post-acute phase was directed at improving joint range-of-motion. Proportionally, more physiotherapists from rural areas treated patients in out-patient hospital departments (59 %), whereas a higher proportion in urban physiotherapists saw patients in private clinics (48 %). Across the continuum of care, treatment was primarily delivered on an individual basis rather than in a group format.
Variation of practice reported with pre-and post-operative care in the community will stimulate dialogue within the profession as to what is the minimal standard of care to provide patients undergoing TJA.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
This study compared functional outcomes at 3 months after hip fracture surgery between nursing home residents participating in a 10-week outreach rehabilitation program and those ...receiving usual care. Function, health-related quality of life, and mortality were also compared over 12 months, and outreach program feasibility was assessed.
Methods
A feasibility trial was undertaken in Canadian nursing homes; of 77 participants, 46 were allocated to Outreach and 31 to Control prior to assessing function or cognition. Outreach participants received 10 weeks of rehabilitation (30 sessions), and Control participants received usual posthospital fracture care in their nursing homes. The primary outcome was the Functional Independence Measure Physical Domain (FIMphysical) score 3 months post-fracture; we also explored FIM Locomotion and Mobility. Secondary outcomes were FIM scores, EQ-5D-3L scores, and mortality over 12 months. Program feasibility was also evaluated.
Results
The mean age was 88.7 ± 7.0 years, 55 (71%) were female, and 58 (75%) had severe cognitive impairment with no significant group differences (p > .14). Outreach participants had significantly higher FIM Locomotion than usual care (p = .02), but no significant group differences were seen in FIMphysical or FIM Mobility score 3 months post-fracture. In adjusted analyses, Outreach participants reported significant improvements in all FIM and EQ-5D-3L scores compared with Control participants over 12 months (p < .05). Mortality did not differ by group (p = .80). Thirty (65%) Outreach participants completed the program.
Conclusions
Our feasibility trial demonstrated that Outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual postfracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, Outreach participants also showed sustained benefits in physical function and health-related quality of life.
Abstract
Background
Providing physical therapists with evidence-based and consensus-derived guidelines to manage postoperative shoulder patients is essential; these guidelines should be readily ...available and provide clinically applicable information. Knowledge translation (KT) initiatives that encourage interaction between clinicians and researchers, that have multifaceted components and use a variety of strategies, can significantly change practice.
Objective
The objective of this study was to determine the uptake and acceptability of standardized postoperative shoulder guidelines with an accompanying online KT resource through evaluation of website analytics and a quantitative survey.
Design
A multi-pronged approach was used to assess uptake and acceptability of the guidelines and online KT resource.
Methods
Website analytics of usage and geographical location of users was measured as were physical therapist survey responses.
Results
Website analytics revealed that 5406 individuals used the online resource between October 2012 and September 2013 with the average visit lasting 8 minutes; only 47% of users were within the guideline developers’ surgical referral region. Physical therapists who used the new shoulder guidelines were very satisfied or satisfied (96%) with the guidelines, reporting they promoted patient-specific clinical decision-making extremely or very well (68%). They viewed the online KT resource positively, with 79% rating it as “very useful” or “quite useful.” Physical therapists from regions beyond those expected to use the new shoulder guidelines were also aware of the website and also rated it as very useful.
Limitations
The survey sample was relatively small and did not directly assess patient outcomes.
Conclusions
An online KT web resource developed in conjunction with standardized postoperative shoulder guidelines was perceived as useful based on website analytics and survey responses. Active KT strategies such as this can improve uptake and dissemination of best practice in physical therapy.
To determine the effectiveness of a preoperative exercise/education program on functional recovery, health related quality of life (HRQOL), health service utilization, and costs following primary ...total knee arthroplasty (TKA).
One hundred thirty-one subjects were randomized to either the control (n = 66) or treatment (n = 65) group 6 weeks before TKA surgery. Patients in the treatment group underwent a 4-week exercise/education program before surgery. All subjects were assessed 6 weeks preoperatively (before the exercise/education intervention), immediately preoperatively (after the exercise/education intervention), and 3, 6 and 12 months after surgery utilizing the Western Ontario McMaster Osteoarthritis Index, the SF-36, and knee range of motion (ROM) and strength measures. Data on length of stay, numbers of community rehabilitation or homecare visits following discharge from the surgical hospital, and the costs associated with these services were also collected.
Subjects were similar in demographic characteristics and all measurements at the baseline assessment. No differences were seen in knee measurements (ROM and strength), pain, function, or HRQOL between the 2 groups following the intervention program or at any postoperative measurement point. Patients in the treatment group used fewer postoperative rehabilitation services and stayed for a shorter time in hospital than the control group, but these differences did not attain statistical significance.
The exercise/education intervention did not alter functional recovery or HRQOL following TKA. Health service utilization was less in the treatment group, but our study was underpowered to attain statistical significance for these measures.
Complex elective foot and ankle surgery is known to be painful so most patients are prescribed opioids at the time of surgery; however, the number of patients prescribed opioids while waiting for ...surgery in Canada is unknown. Our primary objective was to describe the pre and postoperative prescribing practices for patients in Alberta, Canada undergoing complex elective foot and ankle surgery. Secondarily, we evaluated postoperative opioid usage and hospital outcomes.
In this population-based retrospective analysis, we identified all adult patients who underwent unilateral elective orthopedic foot and ankle surgery at a single tertiary hospital between May 1, 2015 and May 31, 2017. Patient and surgical data were extracted from a retrospective chart review and merged with prospectively collected, individual level drug dispensing administrative data to analyze opioid dispensing patterns, including dose, duration, and prescriber for six months before and after foot and ankle surgery.
Of the 100 patients, 45 had at least one opioid prescription dispensed within six months before surgery, and of these, 19 were long-term opioid users (> 90 days of continuous use). Most opioid users obtained opioid prescriptions from family physicians both before (78%) and after (65%) surgery. No preoperative non-users transitioned to long-term opioid use postoperatively, but 68.4% of the preoperative long-term opioid users remained long-term opioid users postoperatively. During the index hospitalization, preoperative long-term opioid users consumed higher doses of opioids (99.7 ± 120.5 mg/day) compared to opioid naive patients (28.5 ± 36.1 mg/day) (p < 0.001). Long-term opioid users stayed one day longer in hospital than opioid-naive patients (3.9 ± 2.8 days vs 2.7 ± 1.1 days; p = 0.01).
A significant number of patients were dispensed opioids before and after foot and ankle surgery with the majority of prescriptions coming from primary care practitioners. Patients who were prescribed long-term opioids preoperatively were more likely to continue to use opioids at follow-up and required larger in-hospital opioid dosages and stayed longer in hospital. Further research and education for both patients and providers are needed to reduce the community-based prescribing of opioid medication pre-operatively and provide alternative pain management strategies prior to surgery to improve postoperative outcomes and reduce long-term postoperative opioid use.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Up to 40% of patients are receiving opioids at the time of total knee arthroplasty (TKA) in the United States despite evidence suggesting opioids are ineffective for pain associated with arthritis ...and have substantial risks. Our primary objective was to determine whether preoperative opioid users had worse knee pain and physical function outcomes 12 months after TKA than patients who were opioid-naive preoperatively; our secondary objective was to determine the prevalence of opioid use before and after TKA in Alberta, Canada.
In this retrospective analysis of population-based data, we identified adult patients who underwent TKA between 2013 and 2015 in Alberta. We used multivariable linear regression to examine the association between preoperative opioid use and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function scores 12 months after TKA, adjusting for potentially confounding variables.
Of the 1907 patients, 592 (31.0%) had at least 1 opioid dispensed before TKA, and 124 (6.5%) were classified as long-term opioid users. Long-term opioid users had worse adjusted WOMAC pain and physical function scores 12 months after TKA than patients who were opioid-naive preoperatively (pain score β = 7.7, 95% confidence interval CI 4.0 to 11.6; physical function score β = 7.8, 95% CI 4.0 to 11.6; p < 0.001 for both). The majority (89 (71.8%) of patients who were long-term opioid users preoperatively were dispensed opioids 180-360 days after TKA, compared to 158 (12.0%) patients who were opioid-naive preoperatively.
A substantial number of patients were dispensed opioids before and after TKA, and patients who received opioids preoperatively had worse adjusted pain and functional outcome scores 12 months after TKA than patients who were opioidnaive preoperatively. These results suggest that patients prescribed opioids preoperatively should be counselled judiciously regarding expected outcomes after TKA.
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