Search

Competing Interests: Competing interests: Mohit Bhandari reports research grants from Sanofi, Pendopharm, Ferring and DJO, outside the submitted work. Mitchell Winemaker reports personal fees and nonfinancial support from Stryker Canada, outside the submitted work. No other competing interests were declared.

Introduction: Various definitions of bleeding have been used in perioperative studies without systematic assessment of the diagnostic criteria for their independent association with outcomes important to patients. Our proposed definition of bleeding impacting mortality after noncardiac surgery (BIMS) is bleeding that is independently associated with death during or within 30 days after noncardiac surgery. We describe our analysis plan to sequentially 1) establish the diagnostic criteria for BIMS, 2) estimate the independent contribution of BIMS to 30-day mortality and 3) develop and internally validate a clinical prediction guide to estimate patient-specific risk of BIMS., Methods: In the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) study, we prospectively collected bleeding data for 16 079 patients aged 45 years or more who had noncardiac inpatient surgery between 2007 and 2011 at 12 centres in 8 countries across 5 continents. We will include bleeding features independently associated with 30-day mortality in the diagnostic criteria for BIMS. Candidate features will include the need for reoperation due to bleeding, the number of units of erythrocytes transfused, the lowest postoperative hemoglobin concentration, and the absolute and relative decrements in hemoglobin concentration from the preoperative value. We will then estimate the incidence of BIMS and its independent association with 30-day mortality. Last, we will construct and internally validate a clinical prediction guide for BIMS., Interpretation: This study will address an important gap in our knowledge about perioperative bleeding, with implications for the 200 million patients who undergo noncardiac surgery globally every year. Trial registration: ClinicalTrials.gov, no NCT00512109., Competing Interests: Competing interests: See the end of the article., (Copyright 2017, Joule Inc. or its licensors.)

Background: Postoperative antibiotic prophylaxis is currently the standard of care for patients undergoing total hip and knee arthroplasty. We evaluated the evidence for this practice in the reduction of surgical-site infections., Methods: We systematically searched MEDLINE, Embase and the Cochrane Library for randomized controlled trials (RCTs) published up to Aug. 15, 2014. We included all RCTs that compared postoperative antibiotic prophylaxis with postoperative placebo or no treatment in patients undergoing primary total hip or knee arthroplasty for osteoarthritis. We combined outcomes for surgical-site infection using a random-effects model and quantified heterogeneity using the χ2 test and the I2 statistic. We assessed the overall quality of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Results: We identified 4 RCTs (n = 4036) that met the inclusion criteria. Surgical-site infections occurred in 3.1% (63/2055) of patients in the prophylaxis group and 2.3% (45/1981) in the control group. Postoperative prophylaxis did not reduce the rate of surgical-site infections compared with placebo (risk difference 0.01, 95% confidence interval 0.00 to 0.02; I2 = 26%). This result was robust to sensitivity testing for losses to follow-up. According to the GRADE approach, the overall quality of evidence was very low., Interpretation: The available evidence did not show efficacy of postoperative antibiotic prophylaxis for the prevention of surgical-site infections in patients undergoing total hip or knee arthroplasty. Multicentred RCTs are likely to have an important impact on the confidence in the effect estimate and to change the estimate itself.

Background: We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity., Methods: Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category., Results: The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364-0.631; ≥ 5 d: OR 0.57, 95% CI 0.435-0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274-0.659; ≥ 5 d: OR 0.489, 95% CI 0.314-0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities., Conclusion: Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.

Background: The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR., Methods: We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management., Results: The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice., Conclusion: Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.

Objective: This study was designed to address a recurring observation in our centre that, despite a satisfactory postoperative radiographic limb alignment, some patients are dissatisfied with the alignment and appearance of their operated leg. We carried out a prospective survey to determine patient perception of limb alignment after total knee arthroplasty (TKA) and whether level of satisfaction with alignment affects clinical outcome., Methods: Patients self-rated their alignment, their satisfaction with alignment and their level of knee pain on a visual analogue scale (VAS). Additional outcome measures included pre- and postoperative Knee Society Score (KSS), Oxford Knee Score (OKS) and the Health Survey Short Form (SF-12)., Results: Twenty of 87 (23%) patients were dissatisfied with their new leg alignment and had a poorer perception of pain and range of motion after TKA. Despite this finding, KSS and OKS were no different between patients who were satisfied and those who were dissatisfied with their limb alignment. The SF-12 showed a trend toward lower scores in patients who were dissatisfied with their limb alignment., Conclusions: Satisfaction with perceived limb alignment appears to influence outcome after TKA and is not reflected in current outcome scales. Perhaps patients should be counselled on how alignment is restored and on what to expect of their limb alignment and appearance after TKA.

Introduction: Historically, cemented total hip arthroplasty (THA) femoral stems inserted in varus have yielded poor clinical results. Few studies to date have addressed the question of the effects of varus alignment on cementless stems. We conducted a retrospective review of 125 uncemented THA femoral stems implanted by a single surgeon from 1994 to 1999., Methods: We conducted a retrospective radiographic review of 125 cementless primary THA femoral stems implanted by a single surgeon who used the Watson-Jones approach; we identified 16 stems implanted in varus, defined as >or= 5 degrees and thus analyzed the effect of varus alignment on functional outcome. We matched varus stems to a cohort of 16 nonvarus cementless stems and measured radiographic signs of loosening and subsidence, defined as > 2 mm., Results: At 4 years postsurgery, there was no significant difference in range of motion or in Harris Hip Score (p > 0.5), and no cases showed evidence of radiographic loosening or subsidence (p = 0.226)., Conclusions: Study results suggest there is no consequence of varus femoral alignment in the cementless stems. Although it is not recommended to implant stems in varus, there were no apparent radiographic or clinical consequences observed at up to 4 years postoperative in this small case series.

Objective: To determine the influence of Ontario Workplace Safety and Insurance Board (WSIB) benefits on short-term clinical outcomes of primary unilateral total knee arthroplasty (TKA)., Methods: In a retrospective matched-cohort study at a single tertiary-care arthroplasty centre in Ontario, we compared a study cohort of 38 successive primary TKA patients receiving WSIB benefits from 1998 to 2002 to 38 controls, a matched cohort of non-WSIB patients, comparing Oxford Knee Score and Knee Society Score (both clinical and functional components) as well as flexion and pain variables, preoperatively and at postoperative intervals of 6 weeks, 6 months and 1 year. At least 1 year after their surgery, all patients were asked to complete a non-validated patient satisfaction survey. The number of clinic visits related to the operation was also compared, by means of Ontario Hospital Insurance Plan billing codes for each individual., Results: Preoperative measurements showed the 2 groups to be similar. At follow-up, WSIB patients had significantly higher pain scores, poorer self-perceived functional outcomes and a lower range of knee flexion than the control group. WSIB patients also required more postoperative clinic visits and were more reluctant to answer questions about functional outcome., Conclusions: Short-term outcomes of primary TKA in patients receiving WSIB benefits are inferior to those of non-WSIB patients. WSIB patients are seen more frequently for postoperative follow-up, which we would attribute to the persistence of subjective complaints after TKA.