Optimisation of blood management in total hip (THA) and knee arthroplasty (TKA) is associated with improved patient outcomes. This study aimed to establish the effectiveness of a perioperative blood management programme in improving postoperative haemoglobin (Hb) and reducing the rate of allogenic blood transfusion. This retrospective before and after study involves 200 consecutive patients undergoing elective TKA and THA before (Usual Care group) and after (Intervention group) the introduction of a blood management programme in an Australian teaching hospital. Patients in the Intervention group underwent preoperative treatment for anaemia and received intraoperative tranexamic acid (15 mg/kg). The primary outcomes were to compare postoperative Hb levels and the rate of blood transfusion. Secondary outcomes included measurements of total amount of allogenic blood transfused, transfusion-related complications, postoperative complications, need for inpatient rehabilitation and duration of hospital stay. There were no differences between baseline characteristics between groups. The mean (SD) preoperative Hb was higher in the Intervention group compared to that in the Usual Care group: 138.7 (13.9) vs. 133.4 (13.9) g/L, p = 0.008, respectively. The postoperative day 1 Hb, lowest postoperative Hb and discharge Hb were all higher in the Intervention group (p < 0.001). Blood transfusion requirements were lower in the Intervention group compared to the Usual Care group (6 vs. 20 %, p = 0.003). There were no differences in any of the secondary outcomes measured. Patients who were anaemic preoperatively and who underwent Hb optimisation had higher Hb levels postoperatively (odds ratio 5.7; 95 % CI 1.3 to 26.5; p = 0.024). The introduction of a perioperative blood optimisation programme improved postoperative Hb levels and reduced the rate of allogenic blood transfusion.
Introduction Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment. PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. Methods and analysis Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery. Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. Ethics and dissemination This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. Trial registration number ACTRN12620001295932.
Aims The prevalence of diabetes is rising, and people with diabetes have higher rates of musculoskeletal-related comorbidities. HbA1c testing is a superior option for diabetes diagnosis in the inpatient setting. This study aimed to (i) demonstrate the feasibility of routine HbA1c testing to detect the presence of diabetes mellitus, (ii) to determine the prevalence of diabetes in orthopedic inpatients and (iii) to assess the association between diabetes and hospital outcomes and post-operative complications in orthopedic inpatients. Methods All patients aged ≥54 years admitted to Austin Health between July 2013 and January 2014 had routine automated HbA1c measurements using automated clinical information systems (CERNER). Patients with HbA1c ≥6.5% were diagnosed with diabetes. Baseline demographic and clinical data were obtained from hospital records. Results Of the 416 orthopedic inpatients included in this study, 22% (n = 93) were known to have diabetes, 4% (n = 15) had previously unrecognized diabetes and 74% (n = 308) did not have diabetes. Patients with diabetes had significantly higher Charlson comorbidity scores compared to patients without diabetes (median, IQR; 1 [0,2] vs 0 [0,0], p<0.001). After adjusting for age, gender, comorbidity score and estimated glomerular filtration rate, no significant differences in the length of stay (IRR = 0.92; 95%CI: 0.79–1.07; p = 0.280), rates of intensive care unit admission (OR = 1.04; 95%CI: 0.42–2.60, p = 0.934), 6-month mortality (OR = 0.52; 95%CI: 0.17–1.60, p = 0.252), 6-month hospital readmission (OR = 0.93; 95%CI: 0.46–1.87; p = 0.828) or any post-operative complications (OR = 0.98; 95%CI: 0.53–1.80; p = 0.944) were observed between patients with and without diabetes. Conclusions Routine HbA1c measurement using CERNER allows for rapid identification of inpatients admitted with diabetes. More than one in four patients admitted to a tertiary hospital orthopedic ward have diabetes. No statistically significant differences in the rates of hospital outcomes and post-operative complications were identified between patients with and without diabetes.
To evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal.Retrospective case control study.Level 1 trauma center.Between 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented.Patient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%.When proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Virtual reality (VR) has proved to be a useful technology beyond the field of surgery in areas that are highly dependent on consolidating motor tasks. Despite being reliant on these skills, the uptake of VR in orthopaedics has been extremely limited. Therefore, this study's purpose was to help assess the utility of applying this technology in teaching different experience levels of orthopaedic training. Secondary objectives were to assess enjoyability and feasibility to complete modules prior to surgery.The study explored which experience level of orthopaedic trainee benefits the most from the proposed haptic VR package. Participants completed a total hip arthroplasty module using the Fundamental Surgery package. Qualitative data was collected in the form of a post completion survey of 24 participants. Quantitative data was collected in the form of module completion time and percentage of skills completed.37.5% of participants rated non-training orthopaedic registrars as the experience level that would benefit the most from using VR. 88% of participants would recommend this module to a colleague and found the module very enjoyable (4.2 out of 5). 50% of participants took between 25 and 31.5 min to finish and completed between 80% and 95% of tasks in the module.The study demonstrated that non-training orthopaedic registrars were most likely to benefit using this particular VR package. Most users found the experience to be enjoyable and would recommend it to a colleague. It was also deemed feasible to complete the module prior to performing an operation.
Introduction: Orthopaedic surgeons performing total hip replacements (THR) today are faced with a vast array of options. Inspired by a recent UK study, we wanted to determine the current trend in prosthesis choice, fixation and bearing surfaces used in ‘young’ Australian patients, and to compare this trend to the UK. Methods: A questionnaire identical to that used in the UK study was posted to all current members of the Australian Orthopaedic Association and returned questionnaires were directly compared to the UK results on a percentage‐of‐responses basis. Results: Two hundred and forty‐six valid responses were received. The number of THR reported to be performed by these respondents (15 789) was equivalent to the estimated number of prostheses sold here during the same period (15 624). The UK results showed a predominant use of Charnley and Exeter femoral prostheses, an all‐polyethylene acetabular component, and cement fixation of both the acetabular and femoral components for both their older and younger patients. In younger patients, Australian surgeons favoured uncemented fixation techniques for the femur (57% vs 23%), and especially the acetabulum (85% vs 32%). There was a higher percentage use of modular design (95% vs 67%) and a very high use of ceramic as a bearing surface, 49% ( vs 25%) using it for the femoral head, and 21% ( vs 2%) employing a ceramic‐on‐ceramic bearing combination. Discussion: Despite being privy to the same published papers, the THR prosthesis and fixation preferences of UK and Australian orthopaedic surgeons are markedly different. This may be because of interpretation of papers, peers, personal experience, patient assessment, budgets, institutions, theories, fashions, differences in autonomy and advertising.
ABSTRACT Aim To determine clinical staff's understanding of managing oral medications in patients with restrictions on oral intake. Method An online survey was designed consisting of 4 scenarios featuring a patient who was fasting pre‐surgery, day 1 post‐surgery, nil‐by‐mouth after stroke or had a nasogastric feeding tube in situ . The target population was clinical staff (nursing, medical, pharmacy, dietetics, speech pathology) involved in the management of oral medications and/or patients' oral intake. Medications studied were: aspirin (Cartia) 100 mg mane ; gliclazide (Diamicron MR) 60 mg mane ; atorvastatin (Lipitor) 40 mg mane ; metoprolol (Betaloc) 50 mg bd; levodopa/carbidopa (Sinemet CR) 200/50 tds; ginkgo 7500 complex mane . Respondents could choose to give, withhold, cease, contact someone for advice, change the formulation before giving or choose ‘other’ and make a comment. Results 622 responses were received from clinical staff. When fasting, respondents would give metoprolol (65%) and levodopa (68%) but not aspirin (70%), gliclazide (63%), atorvastatin (50%) and ginkgo (65%). Approximately 10% of respondents would give oral medications to the nil‐by‐mouth patient. The consensus for the nasogastric feeding tube was to give all the medications via the tube, including modified‐ or controlled‐release medications. Conclusion There appeared to be varying understanding of managing oral medications when patients have restrictions on oral intake. This is concerning as it has the potential to result in adverse patient outcomes.
'/%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h10080v5040H0z'/%3e%3cpath stroke='%23fff' stroke-width='.6' d='m0 0 6 3m0-3L0 3' clip-path='url(%23b)' transform='scale(840)'/%3e%3cpath stroke='%23e4002b' stroke-width='.4' d='m0 0 6 3m0-3L0 3' clip-path='url(%23c)' transform='scale(840)'/%3e%3cpath stroke='%23fff' stroke-width='840' d='M2520 0v2520M0 1260h5040'/%3e%3cpath stroke='%23e4002b' stroke-width='504' d='M2520 0v2520M0 1260h5040'/%3e%3cg fill='%23fff'%3e%3cuse xlink:href='%23d' x='2520' y='3780'/%3e%3cuse xlink:href='%23a' x='7560' y='4200'/%3e%3cuse xlink:href='%23a' x='6300' y='2205'/%3e%3cuse xlink:href='%23a' x='7560' y='840'/%3e%3cuse xlink:href='%23a' x='8680' y='1869'/%3e%3cuse xlink:href='%23e' x='8064' y='2730'/%3e%3c/g%3e%3c/svg%3e)
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3cuse xlink:href='%23a' transform='rotate(72 0 0)'/%3e%3cuse xlink:href='%23a' transform='rotate(-72 0 0)'/%3e%3cuse xlink:href='%23a' transform='scale(-1 1) rotate(72)'/%3e%3c/g%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h1200v600H0z'/%3e%3cpath stroke='%23FFF' stroke-width='60' d='m0 0 600 300M0 300 600 0' clip-path='url(%23b)'/%3e%3cpath stroke='%23C8102E' stroke-width='40' d='m0 0 600 300M0 300 600 0' clip-path='url(%23c)'/%3e%3cpath stroke='%23FFF' stroke-width='100' d='M300 0v300M0 150h600' clip-path='url(%23b)'/%3e%3cpath stroke='%23C8102E' stroke-width='60' d='M300 0v300M0 150h600' clip-path='url(%23b)'/%3e%3cuse xlink:href='%23d' fill='%23FFF' transform='matrix(45.4 0 0 45.4 900 120)'/%3e%3cuse xlink:href='%23d' fill='%23C8102E' transform='matrix(30 0 0 30 900 120)'/%3e%3cg transform='rotate(82 900 240)'%3e%3cuse xlink:href='%23d' fill='%23FFF' transform='rotate(-82 519.022 -457.666) scale(40.4)'/%3e%3cuse xlink:href='%23d' fill='%23C8102E' transform='rotate(-82 519.022 -457.666) scale(25)'/%3e%3c/g%3e%3cg transform='rotate(82 900 240)'%3e%3cuse xlink:href='%23d' fill='%23FFF' transform='rotate(-82 668.57 -327.666) scale(45.4)'/%3e%3cuse xlink:href='%23d' fill='%23C8102E' transform='rotate(-82 668.57 -327.666) scale(30)'/%3e%3c/g%3e%3cuse xlink:href='%23d' fill='%23FFF' transform='matrix(50.4 0 0 50.4 900 480)'/%3e%3cuse xlink:href='%23d' fill='%23C8102E' transform='matrix(35 0 0 35 900 480)'/%3e%3c/svg%3e)