Abstract 1181
Use of allogeneic blood in elective procedures should be minimized due to risks of transfusion, potential adverse impact on outcomes, inconvenience to the patient, high cost and limited ...supply of blood. The purpose of this study was to examine the rate of transfusion following elective total hip (THA) and total knee arthroplasties (TKA) within a preoperative and perioperative blood management program and to examine the relationship between clinical and surgical parameters and blood transfusion.
This was a secondary analysis of prospectively collected data of all consented patients who had undergone joint arthroplasty surgery between January and December, 2011. All patients attended a preoperative clinic 7–14 days prior to their surgery. The preoperative hemoglobin (Hgb) was measured. Transfusion rate was calculated for type of surgery (primary vs. revision and unilateral vs. bilateral). Impact of preoperative Hgb, age, sex, Body Mass Index (BMI), estimated blood loss, type of anaesthetic, type of anticoagulant (rivaroxaban vs. no rivaroxaban), surgeon and drop in hemoglobin (preoperative hemoglobin minus lowest post-operative hemoglobin documented on postoperative day 1, 2 or 3) were examined. Descriptive statistics examined the rate of transfusion in different procedures. Univariate analysis examined the relationship between each factor and having a transfusion. Stepwise logistic regression examined the impact of all factors together. Statistical significance was set at p<0.05.
1605 patients 989 females (62%), mean age 66 (SD:11) had surgery during 2011. Primary TKA: Unilateral 821 (51%), Bilateral TKA: 41 (3%), Revision TKA: 91 (6%), Primary THA: 588 (37%), Bilateral THA: 4 (0.02%), Revision THA: 60 (4%). Four percent (4%) of females had an Hgb <120 mg/L and 3% of males had an Hgb <130 mg/L at the preoperative visit. There were 1555 cases done under regional anaesthesia (spinal or epidural) and 129 cases received a general anaesthetic. Sixty-seven patients (4%) had a blood transfusion while in hospital. Thirty percent (30%) of the transfused women and 9% of the men had a low pre-operative Hgb. THA procedures required more transfusions than TKA (p=0.0012). Transfusion was associated with the following individual factors: age ≥ 80 years, female sex, low BMI (<18.5), increased estimated blood loss, larger drop in hemoglobin, type of anticoagulant (4% in rivaroxaban vs. 8% in non-rivaroxaban), revision surgery (vs. primary), simultaneous bilateral arthroplasty, general anesthesia (vs. spinal), and surgeon. Stepwise logistic regression analysis maintained the intra-operative blood loss, drop in Hgb, female sex, and age as significant independent factors in explaining the variation in blood transfusion.
This study was carried out in an independent orthopaedic facility for elective joint surgery. All patients are assessed medically prior to surgery and advised to take supplemental iron for 2 months prior to surgery. Four percent of females and 3% of males were found to be anemic preoperatively. Patients are admitted the morning of their surgery. Approximately 97% of the consented patients had a regional anesthetic (spinal and/or epidural) with sedation. Patients are transferred into the operating room after the anaesthetic was administered. Surgery is carried out without the routine use of cell saver, tranexamic acid or drains. Approximately 50% of the surgeons deflate the tourniquet in a total knee arthroplasty prior to closure of the capsule. Thromboprophylaxis is initiated with rivaroxaban 10 mg on postoperative day 1. The general transfusion trigger for symptomatic patients is a hemoglobin of 80 g/L. Transfusions can be ordered by staff surgeon, hospitalist, medical consultant or Orthopaedic fellow. The blood bank does not group and screen patients scheduled for routine primary total hip or total knee arthroplasty. Following these practices, we observed a transfusion rate for primary THA of 5% and primary TKA of 3% while using rivaroxaban for thromboprophylaxis starting on postoperative day 1.
The present study confirmed that intra-operative blood loss, drop in the hemoglobin, being a female, and older than 80 years of age as risk factors in relation to need for blood transfusion following elective total joint arthroplasty. Transfusion rates were not higher when rivaroxaban was used for thromboprophylaxis.
Murnaghan:Bayer Healthcare: Honoraria, Research Funding. Off Label Use: Rivaroxaban was used perioperatively for thromboprophylaxis. Our protocol gave the intial dose on postoperative day 1 rather than the 6–10 hours post-operatively recommended by the manufacturer in product monograph. Gollish:Bayer Healthcare: Honoraria, Research Funding.
Abstract 501
Rivaroxaban is an oral Factor Xa inhibitor which has been licensed in Canada since 2008 and the United States since 2011 for the prevention of thromboembolic events following total hip ...and total knee arthroplasties. Multicentre research trials have shown clinical efficacy for prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE). The aim of this study was to prospectively document the incidence and timing of thromboembolic and bleeding events in patients who received rivaroxaban as the primary prophylaxis in clinical practice.
Prospective, observational study of patients given oral Factor Xa inhibitor (rivaroxaban) following primary and revision Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). All patients were approached to participate and consent obtained. Patients treated with Rivaroxaban 10 mg po daily starting Post-Operative Day (POD) #1 and continued for 15 days. This protocol was approved for use at this institution and is NOT consistent with manufacturer’s recommended dosing. All participants were followed up at 6 weeks and 3 months. Doppler ultrasound or venograms used to diagnose symptomatic proximal DVT at or above the popliteal vein. Spiral CT angiogram, angiogram or ventilation/perfusion V/Q scan were used to diagnose PE. All Doppler Ultrasound reports were reviewed by a radiologist to confirm findings and all spiral CT, CT angiogram or ventilation/perfusion scans or images were reviewed (where possible) to verify findings. Bleeding complications were documented as ‘on prophylaxis' starting 2 hours after first dose of anticoagulant therapy until 24 hours after the 15thdose. All major and non-major bleeding events were reviewed by an internist to confirm severity of bleeding episode. Event rates are reported. Data reported on consented patients only. Research ethics approval was obtained for this study.
From June 2010 to Dec 2011, 2888 patients underwent total joint arthroplasty. Two thousand five hundred and thirty-five (88%) agreed to participate in the study. One hundred and fifty patients were treated with thromboprophylaxis other than rivaroxaban. Two thousand three hundred and forty-two were followed up at 3 months (98%). Forty-three patients were lost to follow-up. Complete data on 2342 patients is reported: 905 men, 1437 women with mean age 66 years. Total knees 1353 (primary 1229, revision 123, uni 1). Total hips 989 (primary 899, revision 90).
Three DVT were reported at 6 weeks. Nine additional DVT's were reported at 3 months: 5 primary TKA and 6 Primary THAs 1 Rev THA. Total DVT= 12/2342= 0.5% (see Fig 1).
There were 7 confirmed PE during the first week post op: 6 primary TKA and 1 primary THA. Three additional PE's 6 weeks: 3 THA and 1 TKA. Five additional PE's reported at 3 months:4 THA and 1 TKA. Total PE 16/2342=0.7% (See Fig 2).
There have been 4 perioperative deaths. None were related to surgery, DVT, pulmonary embolism or bleeding.
No major and 9 non-major surgical-site bleeds occurred. All but one were in primary THA. One major and 6 non-major non-surgical site bleeds occurred in patients who received rivaroxaban. Two additional major Non-surgical site bleeds occurred after having received rivaroxaban: one patient received only one dose of rivaroxaban and the other occurred 3–4 days after completion of treatment. Overall Major bleeds 0.04% and Non-Major bleeds 15/2342=0.6%.
One hundred and fourteen patients (5%) received blood transfusions. Transfusion rates by procedure: unilateral THA 4%, Bilateral THA 40%, RTHA 27, unilateral PTKA 3%, bilateral TKA 16%,unicompartmental knee 0% and revision TKA 6%. No routine blood salvage or drains used for primary arthroplasties.
The incidence of thromboembolic events within a period of 3 months was 12/2342=0.6% for DVT and 16/2342=0.7% for PE. The incidence of major bleeding was 0.04%. There were no deaths related to DVT, PE or bleeding. Preliminary results are surprising for the number of pulmonary emboli which occurred while patients were still in hospital and for the number of DVT's which occurred between 6 weeks and 3 months. The early PE's tended to occur in primary TKA. The late events tended to occur in primary THA and TKA. Display omitted Display omitted
Murnaghan:Bayer Healthcare: Honoraria, Research Funding. Off Label Use: rivaroxaban is used for thromboprophylaxis after total joint replacement. our protocol gives first dose on day after surgery. Gollish:Bayer Healthcare: Honoraria, Research Funding.
To determine whether reporting neuropathic pain (NP) at an average of 5 years after total knee arthroplasty (TKA) was related to patient age, sex, preoperative comorbidity, arthritis self-efficacy, ...or disability before surgery and at 1 year after surgery. The estimate of NP prevalence and cross-sectional group differences were explored at 5 years after surgery.
A subsample of participants in a formal research study was contacted via mail approximately 5 years after undergoing surgery and were sent four questionnaires: the Western Ontario and McMaster Universities Osteoarthritis Index, the Patient Health Questionnaire, the Self-Administered Leeds Assessment of Neuropathic Signs and Symptoms (S-LANSS), and a satisfaction questionnaire. NP was defined as an S-LANSS score of 12 or more.
Of 89 patients who met the inclusion criteria, data for 63 (71%) patients (47 women; mean age 67 SD 8 y) were used for analysis. Of these 63, 9 (14%) were identified as having NP. None had a report of failure of prosthesis or other surgical complications according to most recent medical records. There was no relationship between preoperative patient characteristics and development of NP. However, the NP group on average had a higher report of stiffness (p=0.020), physical dysfunction (p=0.019), and pain (p=0.050) at 1 year after surgery. Cross-sectional comparisons showed higher levels of pain (p=0.001), stiffness (p=0.008), physical dysfunction (p=0.003), and depression (p=0.005) and lower satisfaction (p=0.018) at the time of the survey than the patients without NP.
The estimated prevalence of NP was 14%. Patients with NP reported higher levels of disability as early as 1 year after surgery. They remained more disabled, with a higher level of depression and less satisfaction, at an average of 5 years after surgery.
This study was a formative evaluation of a 2-year Surgical Skills Center Curriculum (SSCC) using objective measures of surgical performance and self-reported process-oriented evaluations.
Fifty ...postgraduate third-year (PGY-3) residents participated in an Objective Structured Assessment of Technical Skills (OSATS) examination. Nineteen residents underwent the SSCC and 31 residents did not. During the SSCC, self-reported student and faculty evaluations were completed after each session.
For the OSATS examination, scores were not significantly different between treatment and control groups, on either the checklist (66.4 ± 6.1 versus 64.1 ± 10.8) or global rating scale scores (66.9 ± 6.9 versus 68.0 ± 9.6). Further comparisons between groups on individual OSATS stations revealed no significant differences between groups. The majority of student and faculty evaluation remarks were highly positive.
The OSATS results failed to support our hypothesis that training on a core procedure in a single session during a SSCC would have an appreciable and sustained effect after 2 years. Self-reported process-oriented evaluations support the utility of our SSCC.
The primary objective of this study was to establish the frequency of preoperative anemia (Hb<130g/L) in patients undergoing hip and knee arthroplasty. The secondary objective was to improve anemia ...optimization by identifying anemia earlier in the preoperative phase.
The study was a prospective analysis of preoperative patients undergoing joint arthroplasty. A CBC was done at the first clinic visit (as opposed to the usual second visit). Patients were asked about any history of anemia. A ferritin was added if there was a history of anemia. Anemic patients were referred to the blood conservation clinic for treatment of anemia.
782 patients were seen during the nine month study period. 365 patients were enrolled. 65% were female. The incidence of anemia was 21%. 68 patients had ferritins measured: 10 patients (15%) had iron deficiency (ferritin <30μg/L). Overall, the transfusion rate for all procedures during the study period was 3.6% (52/1439 cases) compared to 5.1% (75/1463 cases) in the previous year.
Anemia is common in patients undergoing hip and knee replacement surgery. Early identification of preoperative anemia allows more time for hemoglobin optimization and may contribute to fewer transfusions perioperatively.
Accurate self-assessment is an important but underdeveloped skill in medicine that, in the past, has received little formal attention from educators.
Following an orthopedic rotation, twenty-five ...orthopedic surgery residents performed a self-assessment task for ten skills using a new relative ranking method, in which an individual's skills are ranked relative to each other rather than being compared to the individual's peers. Supervising faculty assessed residents using the same instrument. Faculty inter-rater reliability was measured and comparisons were made between each resident's self-assessment and the faculty assessments using Spearman rank order correlation coefficients.
The mean correlation between faculty rating the same resident was 0.27 (sd = 0.49). The mean correlation between resident and faculty rankings was 0.20 (sd = 0.38), but was higher for junior residents (0.33) than for senior residents (0.12), apparently because senior residents do not alter their self-assessments while faculty change their assessments of senior residents.
Consistent with the literature in other fields, we find that self-assessment is poor among surgical trainees when they are asked to assess their own performance over an extended time period.
Mobile apps are being viewed as a new solution for post-operative monitoring of surgical patients. Mobile phone monitoring of patients in the post-operative period can allow expedited discharge and ...may allow early detection of complications.
The objective of the current study was to assess the feasibility of using a mobile app for the monitoring of post-operative quality of recovery at home following surgery in an ambulatory setting.
We enrolled 65 consecutive patients (n=33, breast reconstruction surgery; n=32, orthopedic surgery) and asked them to use a mobile phone daily to complete a validated quality of recovery scale (QoR-9) and take photographs of the surgical site for the first 30 days post-op. Surgeons were asked to review patient-entered data on each patient in their roster daily. A semistructured questionnaire was administered to patients and surgeons to assess satisfaction and feasibility of the mobile device.
All 65 patients completed the study. The mean number of logins was 23.9 (range 7-30) for the breast patients and 19.3 (range 5-30) for the orthopedic patients. The mean number of logins was higher in the first 14 days compared to the 15-30 days post-op for both breast patients (13.4 vs 10.5; P<.001) and for the orthopedic patients (13.4 vs 6.0; P<.001). The mean score for overall satisfaction with using the mobile device was 3.9 for breast patients and 3.7 for orthopedic patients (scored from 1 (poor) to 4 (excellent)). Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency.
The use of mobile apps for monitoring the quality of recovery in post-operative patients at home was feasible and acceptable to patients and surgeons in the current study. Future large scale studies in varying patient populations are required.
Simulation-based learning is increasingly prevalent in many surgical training programs, as medical education moves toward competency-based curricula. In orthopaedic surgery, developmental dysplasia ...of the hip is a commonly treated condition, where the standard of care for patients less than six months of age is an orthotic device such as the Pavlik harness. However, despite widespread use of the Pavlik harness and the potential complications that may arise from inappropriate application, we know of no previously described formal training curriculum for Pavlik harness application.
We developed a video and model-based simulation learning module for Pavlik harness application. Two novice groups (residents and allied health professionals) were exposed to the module and, at pre-intervention, post-intervention, and retention testing, were evaluated on their ability to apply a Pavlik harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skills (OSATS) and a global rating scale (GRS) specific to Pavlik harness application. A control group that did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik harness alone would affect skill acquisition. All groups were compared with a group of clinical experts, whose scores were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t tests and analysis of variance (ANOVA).
Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik harness (p < 0.05) to the level of the expert clinicians, and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve, nor did they achieve competency.
The simulation-based learning module was shown to be an effective tool for teaching the application of a Pavlik harness, and learners demonstrated retainable skills post-intervention. This learning module can form the cornerstone of formal teaching of Pavlik harness application for developmental dysplasia of the hip.
Background:
Arthroscopic shoulder stabilization is known to have excellent functional results, but many patients do not return to their preinjury level of sport, with return to play rates reported ...between 48% and 100% despite good outcome scores.
Purpose:
To understand specific subjective psychosocial factors influencing a patient’s decision to return to sport after arthroscopic shoulder stabilization.
Study Design:
Case series; Level of evidence, 4.
Methods:
Semistructured qualitative interviews were conducted with patients aged 18 to 40 years who had undergone primary arthroscopic shoulder stabilization and had a minimum 2-year follow-up. All patients participated in sport before surgery without any further revision operations or shoulder injuries. Qualitative data analysis was performed in accordance with the Strauss and Corbin theory to derive codes, categories, and themes. Preinjury and current sport participation was defined by type, level of competition, and the Brophy/Marx shoulder activity score. Patient-reported pain and shoulder function were also obtained.
Results:
A total of 25 patients were interviewed, revealing that fear of reinjury, shifts in priority, mood, social support, and self-motivation were found to greatly influence the decision to return to sport both in patients who had and had not returned to their preinjury level of play. Patients also described fear of sporting incompetence, self-awareness issues, recommendations from physical therapists, and degree of confidence as less common considerations affecting their return to sport.
Conclusion:
In spite of excellent functional outcomes, extrinsic and intrinsic factors such as competing interests, kinesiophobia, age, and internal stressors and motivators can have a major effect on a patient’s decision to return to sport after arthroscopic shoulder stabilization. The qualitative methods used in this study provide a unique patient-derived perspective into postoperative recovery and highlight the necessity to recognize and address subjective and psychosocial factors rather than objective functional outcome scores alone as contributing to a patient’s decision to return to play.
Transient femoral nerve palsy is a potential complication of the use of a Pavlik harness to treat developmental dysplasia of the hip. Our hypothesis was that patients who develop a femoral nerve ...palsy while undergoing Pavlik harness treatment for developmental dysplasia of the hip are more likely to have unsuccessful orthotic treatment and to require closed or open hip reduction.
We performed a retrospective review of all patients who underwent Pavlik harness treatment for developmental dysplasia of the hip within a seventeen-year period (1992 to 2008). All cases of femoral nerve palsy were identified and reviewed. Thirty infants met the study criteria and formed the palsy group. A control group of seventy-nine infants who did not develop femoral nerve palsy during treatment was randomly selected.
Thirty cases of femoral nerve palsy were identified from a group of 1218 patients for an incidence of 2.5%. Eighty-seven percent of femoral nerve palsies presented within one week of application of the Pavlik harness. Femoral nerve palsy was more likely in older, larger patients in whom the developmental dysplasia of the hip was of higher severity. Patients whose femoral nerve palsy resolved within three days had a 70% chance of having successful treatment with the Pavlik harness, whereas those who had not recovered by ten days had a 70% chance of having treatment failure with the Pavlik harness. The success rate associated with treatment with a Pavlik harness was 94% in our control group and 47% in our palsy group.
Femoral nerve palsy is an uncommon yet clinically important complication of Pavlik harness treatment for developmental dysplasia of the hip. This complication is strongly predictive of failure of treatment, and its impact is greatest when the developmental dysplasia of the hip is higher in severity. Early recognition and management of femoral nerve palsies may improve the success of treatment.
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