Orthopaedic Education During the COVID-19 Pandemic Kogan, Monica; Klein, Sandra E; Hannon, Charles P ...
Journal of the American Academy of Orthopaedic Surgeons,
2020-June-1, Letnik:
28, Številka:
11
Journal Article
Recenzirano
Odprti dostop
The COVID-19 global pandemic presents a challenge to orthopaedic education. Around the world, including in the United States, elective surgeries are being deferred and orthopaedic residents and ...fellows are being asked to make drastic changes to their daily routines. In the midst of these changes are unique opportunities for resident/fellow growth and development. Educational tools in the form of web-based learning, surgical simulators, and basic competency tests may serve an important role. Challenges are inevitable, but appropriate preparation may help programs ensure continued resident growth, development, and well-being while maintaining high-quality patient care.
Serum albumin level is the most well-established serum marker of malnutrition, with a serum albumin concentration <3.5 g/dL considered to be suggestive of malnutrition. The purpose of this study was ...to test if serum albumin level is associated with death, specific postoperative complications (e.g., pneumonia), length of hospital stay, and readmission following a surgical procedure for geriatric hip fracture.
A retrospective cohort study of geriatric patients (≥65 years of age) undergoing a hip fracture surgical procedure as part of the American College of Surgeons National Surgical Quality Improvement Program was conducted. Outcomes were compared between patients with and without hypoalbuminemia. All comparisons were adjusted for baseline and procedural differences between populations, and patients with missing serum albumin concentration were included in analyses using a missing data indicator.
There were 29,377 geriatric patients undergoing a hip fracture surgical procedure who met inclusion criteria; of these patients, 17,651 (60.1%) had serum albumin available for analysis. The prevalence of hypoalbuminemia was 45.9%. Following adjustment for baseline and procedural characteristics, the risk of death was inversely associated with serum albumin concentration as a continuous variable (adjusted relative risk, 0.59 95% confidence interval (CI), 0.53 to 0.65; p < 0.001). In comparison with patients with normal albumin concentration, patients with hypoalbuminemia had higher rates of death (9.94% compared with 5.53% adjusted relative risk, 1.52 (95% CI, 1.37 to 1.70); p < 0.001), sepsis (1.19% compared with 0.53% adjusted relative risk, 1.92 (95% CI, 1.36 to 2.72); p < 0.001), and unplanned intubation (2.64% compared with 1.47% adjusted relative risk, 1.51 (95% CI, 1.21 to 1.88); p < 0.001). The mean length of stay (and standard deviation) was longer among patients with hypoalbuminemia at 5.67 ± 4.68 days compared with those without hypoalbuminemia at 4.99 ± 3.95 days; the adjusted difference was 0.50 day (95% CI, 0.38 to 0.63 day; p < 0.001). However, the rate of readmission did not differ (p = 0.054) between patients with hypoalbuminemia (10.91%) and those without hypoalbuminemia (9.03%); the adjusted relative risk was 1.10 (95% CI, 1.00 to 1.21).
Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture. These data suggest that further investigation into postoperative nutritional supplementation is warranted to decrease the risk of complications.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Little is known regarding the impact of operative time on adverse events following arthroplasty. The present study tests for associations between a 15-minute increase in operative time and the ...occurrence of adverse events following primary total joint arthroplasty.
Patients undergoing primary total hip or knee arthroplasty during 2006-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as a continuous variable) was tested for association with perioperative outcomes using multivariate regression. All regressions were adjusted for differences in demographic, comorbidity, and procedural characteristics.
A total of 165,474 patients met inclusion criteria. The mean (±standard deviation) operative time was 91.9 ± 32.5 minutes. Following adjustment for baseline characteristics, an increase in operative time by 15 minutes increased the risk of anemia requiring transfusion by 9% (95% confidence interval CI = 8%-10%, P < .001), wound dehiscence by 13% (95% CI = 8%-19%, P < .001), renal insufficiency by 9% (95% CI = 3%-14%, P < .001), sepsis by 10% (95% CI = 6%-14%, P < .001), surgical site infection by 9% (95% CI = 7%-12%, P < .001), and urinary tract infection by 4% (95% CI = 2%-6%, P < .001). Similarly, an increase in operative time by 15 minutes increased the risk of hospital readmission by 5% (95% CI = 4%-6%, P < .001) and of extended hospital length of stay (≥4 days) by 9% (95% CI = 8%-10%, P < .001).
The present study suggests that greater operative time increases the risk for multiple postoperative complications following total joint arthroplasty. These data suggest that surgeons should consider steps to minimize operative time without compromising the technical components of the surgical procedure.
Background:
Although many studies have reported successful functional outcomes after proximal tibial osteotomy (PTO), a paucity of literature has sought to quantify outcomes and current rates of ...return to sport (RTS) and return to work (RTW) after PTO.
Purpose:
To (1) determine current rates of RTS and RTW after PTO and (2) quantify the incidence of complications and conversion to total knee arthroplasty (TKA) after PTO for all patients as well as those undergoing opening and closing wedge PTO.
Study Design:
Systematic review and meta-analysis; Level of evidence, 4.
Methods:
The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) databases were queried. Data pertaining to article information, patient demographics, surgical techniques, rates of complication and conversion to TKA, patient-reported outcome scores, RTS, and RTW were extracted. Data were synthesized, and a random effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients receiving opening and closing wedge PTO who experienced adverse events.
Results:
The review and meta-analysis included 33 studies involving 1914 patients who underwent PTO with a weighted mean ± SD age of 50.3 ± 9.9 years and body mass index of 26.9 ± 2.3 kg/m2. The pooled RTS and RTW rates were 75.7% (range, 55%-100%) in 814 patients and 80.8% (range, 41%-100%) in 505 patients, respectively. The pooled TKA rate was 12.5% (range, 0%-35.7%) at a mean of 70.6 months and the pooled complication rate was 11.1% (range, 0%-28.6%). The overall random pooled summary estimate of the proportion of patients who underwent opening wedge PTO and subsequently converted to TKA was 2.0% (95% CI, 1.0%-4.0%; I2 = 63.65) at a mean of 43.4 ± 31.9 months and who experienced a complication was 6.0% (95% CI, 3.0%-9.0%; I2 = 87.10%). For closing wedge PTO, the proportion of patients who converted to TKA was 5.0% (95% CI, 1.0%-9.0%; I2 = 93.1%) and experienced a complication was 2.0% (95% CI, 1.0%-3.0%; I2 = 90.0%). Only 53.8% of studies that referenced RTS provided postoperative RTS rates, and 80% of studies that referenced RTW provided RTW rates. Only 1 study defined RTS criteria, no studies defined RTW criteria, and 31 different outcome measures were reported across all studies.
Conclusion:
Patients undergoing PTO for osteoarthritis, cartilage defects, and symptomatic malalignment of the knee experience high rates of RTS and RTW. These patients also experience low rates of complications and conversion to TKA, regardless of opening or closing wedge technique. Significant heterogeneity exists with regard to criteria used to define RTS and RTW and patient-reported outcome measures used to assess clinical and functional improvements after PTO.
To perform a systematic review of randomized controlled trials on the use of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease.
Using Preferred Reporting Items for ...Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers independently screened the MEDLINE, Embase, and Cochrane Library databases for prospective, randomized controlled trials comparing PRP with a control in the nonoperative treatment of chronic rotator cuff disease for inclusion. Clinical data were extracted and evaluated. The quality of evidence was assessed using The Cochrane Collaboration risk-of-bias tool.
Five randomized controlled trials met the inclusion criteria, with 108 patients treated with PRP and 106 treated with a control. The mean age was 53.7 years, and 61.6% of patients were female patients. All of the studies found that the groups receiving PRP injections experienced improved clinical outcomes at final follow-up compared with baseline. Two studies found that PRP resulted in improved outcomes, mostly pain scores, compared with a control. One study compared PRP with formal exercise versus a saline solution injection with formal exercise therapy. It showed no difference in clinical outcomes between PRP and a saline solution injection when formal exercise therapy was used. Two other studies reported that PRP alone resulted in inferior outcomes to control groups receiving formal exercise therapy.
The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. When directly compared with exercise therapy, PRP does not result in superior functional outcomes, pain scores, or range of motion. However, interpretation of this literature is confounded by the lack of reporting of the cytology and characteristics of PRP.
Level II, systematic review of Level I and II evidence.
The purpose of this study is to survey the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS).
A ...survey of 28 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018.
There were 622 responses (28.2%) to the survey. A majority of respondents (93.2%, n = 576) use preemptive analgesia prior to total joint arthroplasty. Most respondents use a spinal for total knee arthroplasty (TKA) (74.4%) and total hip arthroplasty (THA) (72.6%). A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200) and after THA is 44 pills (range 0-200). Most surgeons (58%) expect that this prescription should last for 2 weeks. A majority of respondents (74.0%) use multimodal analgesics in addition to opioids.
There is no consensus regarding the optimal multimodal anesthetic and analgesic regimen for total joint arthroplasty among surveyed board-certified arthroplasty surgeon members of AAHKS. Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids.
To review the basic science studies on platelet-rich plasma (PRP) for cartilage and determine whether there has been an improvement in methodology and outcome reporting that would allow for a more ...meaningful analysis regarding the mechanism of action and efficacy of PRP for cartilage pathology.
The PubMed/MEDLINE and EMBASE databases were screened in May 2017 with publication dates of January 2011 through May 2017 using the following key words: “platelet-rich plasma OR PRP OR autologous conditioned plasma (ACP) OR ACP AND cartilage OR chondrocytes OR chondrogenesis OR osteoarthritis OR arthritis.” Two authors independently performed the search, determined study inclusion, and extracted data. Data extracted included cytology/description of PRP, study design, and results.
Twenty-seven studies (11 in vitro, 13 in vivo, 3 in vitro and in vivo) met the inclusion criteria and were included in the study. All of the studies (100%) reported the method by which PRP was prepared. Two studies reported basic cytologic analysis of PRP, including platelet, white blood cell, and red blood cell counts (6.7%). Nine studies reported both platelet count and white blood cell count (30.0%). Twelve studies reported platelet count alone (40.0%). Nine studies (30.0%) made no mention at all as to the composition of the PRP used. PRP was shown to increase cell viability, cell proliferation, cell migration, and differentiation. Several studies demonstrated increased proteoglycan and type II collagen content. PRP decreased inflammation in 75.0% of the in vitro studies reporting data and resulted in improved histologic quality of the cartilage tissue in 75.0% of the in vivo studies reporting data.
Although the number of investigations on PRP for cartilage pathology has more than doubled since 2012, the quality of the literature remains limited by poor methodology and outcome reporting. A majority of basic science studies suggest that PRP has beneficial effects on cartilage pathology; however, the inability to compare across studies owing to a lack of standardization of study methodology, including characterizing the contents of PRP, remains a significant limitation. Future basic science and clinical studies must at a minimum report the contents of PRP to better understand the clinical role of PRP for cartilage pathology.
Establishing proof of concept for PRP to treat cartilage pathology is important so that high-quality clinical studies with appropriate indications can be performed.
Total knee arthroplasty (TKA) has been performed by orthopedic surgeons for decades, but the cementless TKA has only recently gained much interest in the world of arthroplasty. Initially, early ...designs had multiple complications, particularly with aseptic loosening due to osteolysis and micromotion. However, modifications have shown good outcomes and excellent survivorship. Over the last several decades, changes in implant designs as well as implant materials/coatings have helped with bone in growth and stability. Furthermore, surgeons have been performing TKA in younger and more obese patients as these populations have been increasing. Good results from the cementless TKA compared to cemented TKA may be a better option in these more challenging populations, as several studies have shown greater survivorship in patients that are younger and have a greater BMI. Additionally, a cementless TKA may be more cost effective, which remains a concern in today's healthcare environment. Overall, cemented and cementless TKA have great results in modern times and there is still a debate as to which implant is superior.
The number of revision total knee arthroplasties (TKAs) performed annually continues to rise. This article is a summary of a symposium on revision TKAs presented at the 2023 American Association of ...Hip and Knee Surgeons annual meeting. It will provide an overview of the surgical tips and tricks for exposure and component removal, use of metaphyseal fixation and stems to manage bone loss and optimize fixation, constraint in TKA, as well as how to manage extensor mechanism disruptions with a synthetic mesh reconstruction.
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