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Objective Diagnosing septic arthritis can be challenging and frequently involves clinical assessment, laboratory investigations and synovial fluid analysis. We sought to determine the utility of synovial aspiration and intra-operative synovial fluid and tissue culture for the accurate diagnosis of septic arthritis. Methods We carried out a retrospective review of the records of patients referred to a tertiary orthopaedic unit with possible septic arthritis between 2015 and 2019 inclusive, including clinical and laboratory data for this cohort study. Performance characteristics were determined for synovial aspiration, intra-operative synovial fluid and tissue culture in diagnosing expert review-determined true septic arthritis. Concordance between discharge diagnosis, antibiotic prescribing and true septic arthritis was determined. Results Of 268 patients identified with suspected septic arthritis, 143 underwent both synovial fluid aspiration and intra-operative synovial fluid and tissue biopsy culture. True septic arthritis was not differentiated significantly by laboratory parameters including serum white cell count (WCC), CRP or synovial WCC. Considering only patients with negative pre-operative synovial aspirate cultures, intra-operative samples led to diagnosis of true septic arthritis in 6 of 63 patients [number needed to treat (NNT) 10.5]. For all patients sampled in theatre, positive synovial tissue biopsy was the only evidence of true septic arthritis in six (NNT 23.9). Despite insufficient microbiological evidence, 27 of the 59 patients who did not have septic arthritis received a discharge diagnosis of septic arthritis, 26 of whom were discharged with antibiotics. Conclusion Intra-operative sample collection, particularly tissue biopsy, increases the likelihood of a true septic arthritis diagnosis. Such measures might help to reduce diagnostic ambiguity in clinical practice and might therefore reduce overtreatment.

Neisseria meningitidis is a rare cause of prosthetic joint infection (PJI), with only three cases previously reported. Here we report three further cases, all of which were successfully treated with implant retention and short-course antibiotics (

More than 70% of patients continue to use opioid medications 3-weeks following total knee arthroplasty. Post-discharge pharmacist reviews improve medication management, however it's effect on opioid usage is not known.This study aimed to evaluate the impact of post-discharge pharmacist review on opioid use following a total knee arthroplasty.A pilot, cohort pre- and post-intervention study was undertaken on patients who had undergone a total knee arthroplasty and were supplied an opioid upon discharge from hospital. During the intervention, patients were contacted via telephone by a pharmacist approximately five days post-discharge to review analgesic usage, provide education and advice and communicate an opioid management plan to their general practitioner. The primary endpoint was the percentage of patients taking opioids 3-weeks post-discharge. Secondary endpoints included: percentage of patients obtaining an opioid refill; patient satisfaction with opioid supply and the pharmacist review.Pre- and post-intervention, 63 and 44 patients were included, respectively. The percentage of patients taking opioids 3-weeks post-discharge declined from 74.6 to 29.6% (p 0.001) and the percentage requiring an opioid refill from their general practitioner declined from 71.4 to 36.4% (p 0.001). More patients were satisfied with opioid supply during the intervention period (79.5% cf. 47.6%, p = 0.001). Twenty-eight (63.6%) patients could recall the post-discharge pharmacist review, and all were either satisfied or extremely satisfied with the review.Pharmacist-delivered post-discharge analgesia review reduced the percentage of patients taking opioids 3-weeks post-discharge following a total knee arthroplasty. This intervention has the potential to provide a smoother transition of care for patients supplied with opioids at the time of hospital discharge.

Background Three-dimensional (3D) printing has seen increasing interest in surgery, where it improves the visualization of difficult anatomy in complex cases. This literature review investigates the benefits and limitations of 3D printed models in preoperative planning in the field of orthopaedic surgery. Methods A literature search was performed using the Ovid platform on the Embase and MEDLINE databases using the terms '3D printing', 'Orthopaedics' and 'Surgical Planning'. Studies using 3D printed models as a part of preoperative planning were included. All others were excluded. Data regarding the metrics used to assess the benefit of the use of 3D models, surgical outcome, and surgeon or patient opinion on the technology were extracted. Results A total of 41 studies resulted. Eight (19.5%) were case-control studies, the remainder were case reports or case series. Assessment of benefit was mostly subjective, although the case-control studies included objective metrics such as operation time, intraoperative blood loss and intraoperative fluoroscopy time. The use of 3D printing technology showed subjective benefit for both patient and surgeon as well as indicating clinically significant improvements in intraoperative metrics. Conclusion Despite the current absence of large scale trials, 3D printing has clear benefits in preoperative planning, particularly when utilized in complex cases. A streamlined workflow for case selection, in-house model creation and preoperative rehearsals is still required to be developed before the process is ready for routine use. Evidence supports an improvement in intraoperative metrics and patient engagement but data to support improved clinical outcome is lacking.

Injury to femoral arterial vessels is a risk with internal fixation of the hip. Understanding the anatomy of proximate vessels, particularly medial vessels not directly visualized, may reduce intraoperative and postoperative complications.We analyzed 47 patients (29 men and 18 women) using a computed tomographic (CT) angiogram of the lower limbs. The mean age of our patients was 69 years (range, 46 to 88 years). The distance from the tip of the greater trochanter to the profunda femoris and its perforators within 5 mm of the medial femoral shaft was measured along the length of the expected placement of typical dynamic hip screw constructs and other proximal femoral fracture fixation methods.All patients were found to have 2 perforator vessels within 5 mm of the medial femoral shaft along the line of dynamic hip screw insertion (up to 200 mm from the tip of the greater trochanter). The first perforator was found at a mean distance of 112.6 mm (median, 110 mm) in women and at 123.4 mm (median, 122 mm) in men (p = 0.0066) from the tip of the greater trochanter. The second perforator appeared at a mean distance of 159.7 mm (median, 159 mm) in women and 178.9 mm (median, 180 mm) in men (p = 0.0028) from the tip of the greater trochanter.Surgeons should be aware of the presence of 2 arteries within 5 mm of the medial femoral shaft during femoral internal fixation procedures. We suggest avoiding the overdrilling of the medial cortex and the insertion of overlong screws along the femoral shaft from 110 to 120 mm in women and 120 to 130 mm in men (as measured from the tip of the greater trochanter) to prevent vascular injury during proximal femoral fracture fixation.This article can assist orthopaedic surgeons in planning for procedures involving internal fixation of the hip and may reduce vascular complications from such procedures.

BackgroundManaging medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure.MethodsThe policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications.The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions.The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression.ResultsPre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions.In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions.ConclusionsDistinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.

Background: Biceps tenodesis is a common treatment for proximal long head of biceps (LHB) tendon pathology. To maintain biceps strength and contour and minimize cramping, restoration of muscle-length tension and appropriate positioning of the tenodesis is key. Little is known about the biceps musculotendinous junction (MTJ) anatomy, especially in relation to the overlying pectoralis major tendon (PMT), which is a commonly used landmark for tenodesis positioning. Purpose: To characterize the in vivo topographic anatomy of the LHB tendon, in particular the MTJ relative to the PMT, using a novel axial proton-density magnetic resonance imaging (MRI) sequence. Study Design: Descriptive laboratory study. Methods: In total, 45 patients having a shoulder MRI for symptoms unrelated to their biceps tendon or rotator cuff were prospectively recruited. There were 33 men and 12 women, with a mean age of 37 ± 13 years (range, 18-59 years). All patients underwent routine shoulder MRI scans with an additional axial proton density sequence examining the LHB tendon and its MTJ. Three independent observers reviewed each MRI scan, and measurements were obtained for (1) MTJ length, (2) the distance between the proximal MTJ and the superior border of the PMT (MTJ-S), (3) the distance between the distal MTJ to the inferior border of the PMT, and (4) the width of the PMT. Results: The average position of the MTJ-S was 5.9 ± 10.8 mm distal to the superior border of the PMT. The mean MTJ length was 32.5 ± 8.3 mm and the width of the PMT was 28.0 ± 7.3 mm. We found no significant correlation between patient age, height, sex, or body mass index and any of the biceps measurements. We observed wide variability of the MTJ-S position and identified 3 distinct types of biceps MTJ: type 1, MTJ-S above the PMT; type 2, MTJ-S between 0 and 10 mm below the superior border of the PMT; and type 3, MTJ-S >10 mm distal to the superior PMT. Conclusion: In this study, the in vivo anatomy of the LHB tendon is characterized relative to the PMT using a novel MRI sequence. The results demonstrate wide variability in the position of the MTJ relative to the PMT, which can be classified into 3 distinct subtypes or zones relative to the superior border of the PMT. Understanding this potentially allows for accurate and anatomic placement of the biceps tendon for tenodesis. Clinical Relevance: To our knowledge, this is the first study to radiologically analyze the in vivo topographic anatomy of the LHB tendon and its MTJ. The results of this study provide more detailed understanding of the variability of the biceps MTJ, thus allowing for more accurate placement of the biceps tendon during tenodesis.

Background Early mobilization after surgery is a key recommendation for people with hip fracture, however this is achieved by only 50% of people. Recumbent bike riding has been used in other populations with limited mobility and has potential to allow early exercise in people post hip fracture. The primary aim of this pilot trial was to demonstrate the feasibility of a trial protocol designed to determine the effect of early post-operative cycling in bed on outcomes in people with hip fracture. Methods Single-blinded, multi-site randomized controlled pilot trial. Fifty-one people with hip fracture were recruited within 4 days of surgery from two sites in Victoria. Participants were randomly allocated to receive either usual care (n = 25) or usual care plus active cycling in bed (n = 26). The cycling intervention was delivered on weekdays until the participant could walk 15 m with assistance of one person. The primary outcomes were trial feasibility and safety. Clinical outcomes, including mobility (Modified Iowa Level of Assistance Scale) and delirium were measured at day seven post-operatively and at hospital discharge by an assessor blinded to group. Additional outcomes at discharge included gait speed, cognition and quality of life. Results The intervention was safe, feasible and acceptable to patients and staff. Delivery of the intervention was ceased on (median) day 9.5 (IQR 7, 12); 73% of scheduled sessions were delivered; (median) 4 sessions (IQR 2.0, 5.5) were delivered per participant with (median) 9 min 34 s (IQR 04:39, 17:34) of active cycling per session. The trial protocol was feasible, however at day seven 75% of participants had not met the criterion (able to walk 15 m with assistance of one person) to cease the cycling intervention.. Conclusion In bed cycling is feasible post-operatively following hip fracture, however seven days post-operatively is too early to evaluate the impact of the cycling intervention as many participants were still receiving the intervention. A fully powered RCT to explore the effectiveness and cost efficiency of this novel intervention is warranted. Trial registration The trial was prospectively registered (25/09/2017) with the Australian New Zealand Clinical Trials Registry ACTRN12617001345370.

Background: Rapid response teams (RRTs) are a critical care resource that review deteriorating patients within the hospital. We aimed to describe demographic, preoperative, surgical, anesthetic, and postoperative characteristics of patients who required RRT activation after major hip surgery. We also sought to assess whether these characteristics where associated with mortality during the index hospital admission.Methods: We reviewed an RRT database of adult patients undergoing orthopedic surgery at a university teaching hospital. We then retrospectively reviewed the medical records to extract a priori–defined patient, preoperative, surgical, anesthetic, and postoperative data of major hip surgery admissions between September 2014 and December 2017. Patients who survived the index hospital stay were compared to those who died.Results: Overall, 187 patients had postoperative RRT activations. Median (interquartile range) age was 84.0 (78-90) years; 125 (67%) were female, and most patients had at least one significant comorbidity, median Charlson Comorbidity Index (CCI) 5.0 (4.0-7.0). The majority of patients were frail (68%), American Society of Anesthesiologists physical status Class 3 or greater (91%), and underwent nonelective surgery (88%). Median (interquartile range) time from surgery to RRT activation was 29.4 (11.3–75.0) hours, and 25 (13%) patients had unplanned admissions to intensive care or high dependency units. Compared to patients who survived RRT activation, those who died displayed higher mean CCI (6.5 [1.8] vs. 5.5 [2.1], p = 0.02), were more frail (80.1% vs. 56.5%, OR = 3.2, 95% CI: 1.2,8.1; p = 0.03), and received less intraoperative opioids (intravenous morphine equi-analgesia: median = 5.8 (0.1–8.20 vs. 11.7 (3.7–19.0) mg, p = 0.03). They were also more likely to have received an urgent medical review prior to RRT activation (62% vs. 40%, OR = 2.4, 95% CI: 1.1, 5.6); p = 0.05.Conclusions: Death after RRT activation occurred in 1 in 7 patients undergoing major hip surgery. Common patient characteristics included advanced age (> 82 years), frailty, high CCI, and emergency surgery. Further studies investigating perioperative surveillance teams in the identification of the high-risk patients before surgery and deteriorating patients after major hip surgery are warranted.

Introduction We describe the demographic, preoperative, surgical, anesthetic, and postoperative characteristics of patients who required a rapid response team (RRT) activation after major hip surgery. We determined the characteristics and outcomes of patients that require RRTs after major hip surgery, and their associations with mortality. Presentation of cases We retrospectively reviewed adult patients undergoing major hip surgery in a university teaching hospital. We included patients who had an RRT or “code blue” activation post-surgery and within the index hospital admission. We extracted patient, surgical, anesthetic, and postoperative variables. We explored differences between patients who survived their index hospital stay and those who died. Discussion 187 (9%) patients had a postoperative RRT activation. The median age was 84.0 (78–90) years; 125 (67%) were female, and most patients had significant comorbidities. The median Charlson Comorbidity Index (CCI) was 5.0 (4.0–7.0). Patients were frail (68%), ASA physical status ≥Class 3 (91%) and underwent emergency surgery (88%). Death after RRT activation occurred in 1 in 7 patients. Compared to patients who survived RRT activation, those who died had a higher mean CCI (6.5 [1.8] vs. 5.5 [2.1], P = 0.02), were more frail (80.1% vs. 56.5%, OR = 3.2, 95% CI: 1.2,8.1; P = 0.03), and received less intraoperative opioids (intravenous morphine equi-analgesia: median = 5.8 (0.1–8.20 vs. 11.7 (3.7–19.0) mg, P = 0.03). Conclusion Mortality after RRT activation is associated with non-modifiable patients factors rather than surgical or anesthesia factors. Our findings provide opportunities for the implementation of strategies aimed at improving postoperative outcomes., Highlights • Major hip surgery poses a significant physiological challenge to patients. • Almost one in ten patients had a postoperative rapid response team activation. • Mortality rate was one in seven patients following rapid response team activation. • Advanced age, frailty and emergency surgery were associated with RRT activation. • Death post RRT activation was not associated with surgical or anesthesia factors.

Introduction Effective pain management after joint arthroplasty is essential for optimal participation in rehabilitation. However, this needs to be balanced with potential risks associated with opioid use and community exposure. The aim of this study was to evaluate opioid use and appropriateness of supply on discharge after total knee arthroplasty or total hip arthroplasty at a major Australian health service. Methods A prospective observational study was undertaken at an Australian 980-bed metropolitan health service. Patient interviews were conducted 3 weeks after hospital discharge to evaluate analgesic management and functional outcomes. The primary end point was the number of hospital-supplied opioid pills remaining 3 weeks postdischarge. Secondary end points included (1) factors associated with opioid use 3 weeks postdischarge, (2) opioid use in patients with poor functional outcomes, and (3) proportion of opioid naive patients who became chronic opioid users. Results One hundred forty patients were included, and 137 were supplied opioids on discharge. At 3 weeks postdischarge, the median number of opioid pills remaining was 0 (interquartile range 0 to 8). There were 77 patients (56.2%) still taking opioids; surgery type, opioid use before admission, and the number of "as required" doses used 24 hours before discharge were independent predictors of opioid continuation. Patients with poor functional outcomes were supplied with more opioids on discharge, often not satisfied with the quantity supplied and more likely to be taking opioids 3 weeks postdischarge. There were 5 of 93 opioid naive patients (5.3%) who developed chronic opioid usage. Discussion More than half of the patients undergoing total knee arthroplasty or total hip arthroplasty were still using opioids at 3 weeks postdischarge. Most patients were not supplied with excessive quantities at discharge. Future research should focus on identifying patients at risk of prolonged opioid use and improving the transition of these patients into the community. Level of evidence Level II-Prognostic study = prospective observational study.

Background: Prescribing and administration errors related to pre-admission medications are common amongst orthopaedic inpatients. Postprescribing medication reconciliation by clinical pharmacists after hospital admission prevents some but not all errors from reaching the patient. Involving pharmacists at the prescribing stage may more effectively prevent errors. The aim of the study was to evaluate the effect of pharmacist-assisted electronic prescribing at the time of hospital admission on medication errors in orthopaedic inpatients. Methods: A pre- and postintervention study was conducted in the orthopaedic unit of a major metropolitan Australian hospital. During the 10-week intervention phase, a project pharmacist used electronic prescribing to assist with prescribing admission medications and postoperative venous thromboembolism (VTE) prophylaxis, in consultation with orthopaedic medical officers. The primary endpoint was the number of medication errors per patient within 72 h of admission. Secondary endpoints included the number and consequence of adverse events (AEs) associated with admission medication errors and the time delay in administering VTE prophylaxis after elective surgery (number of hours after recommended postoperative dose-time). Results: A total of 198 and 210 patients, pre- and postintervention, were evaluated, respectively. The median number of admission medication errors per patient declined from six pre-intervention to one postintervention ( p Conclusions: Pharmacist-assisted electronic prescribing reduced the number of admission medication errors and associated AEs.

Rationale, aims and objectives Inpatient bed access decreases when ward discharge is delayed. This contributes to prolonged emergency department (ED) length of stay (LOS) which has been associated with increased hospital LOS and mortality. Delays in preparation of discharge medication prescriptions by ward doctors may contribute to delayed ward discharge. This project aimed to evaluate the effect on patient flow of having a pharmacist collaborate with ward doctors to prepare discharge prescriptions at a hospital with an electronic prescribing system. Method Eight-week pre- and post-intervention study on two surgical wards at a major metropolitan Australian hospital. During the intervention, a project pharmacist (PP) electronically prepared discharge prescriptions, in consultation with ward doctors, which were reviewed by the regular ward pharmacist before being dispensed. Outcome measures, based on hospital performance indicators, included: Percentage of patients transferred to wards from ED within four and six hours of presentation; Median time (minutes) past 9 am that patients were discharged from the wards; Percentage of patients discharged from wards by 9 am; Staff satisfaction. Results Pre- and post-intervention, there were 259 and 246 patients transferred from ED to the study wards, respectively. The percentage of patients transferred within four and six hours of presentation did not change. There were 320 and 341 patients discharged, pre- and post-intervention, respectively, who required a discharge prescription. The PP prepared 273 (80%) prescriptions during the post-intervention period. Patients were discharged 57 minutes earlier with the intervention (median 211 vs. 154 minutes past 9 am, P = 0.01). The percentage of patients discharged before 9 am increased from 6% to 12% (P = 0.01). All 26 health-professional respondents (79% response rate) were satisfied with the service and recommended its continuation. Conclusions Pharmacist collaboration with doctors to prepare discharge prescriptions did not impact upon ED access targets, but resulted in patients being discharged earlier.

BACKGROUND: Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid Response Teams (RRTs) review patients on hospital wards with hypotension. AIMS: To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors, and areas for future quality improvement. METHODS: Retrospective observational study using data from RRT and clinical informatics databases. Evaluation of timing, presumed causes of hypotension and associated treatments. RESULTS: Amongst 963 RRT activations in 605 patients over three years, 226/605 (37.4%) of first calls were due to hypotension and 213/226 (94.2%) had sufficient data for analysis. The median age was 79 (IQR 66-87) years, 58 (27.2%) were male, and co-morbidities were common. Most (68%) surgery was emergent and 75.1% received intra-operative vasopressors for hypotension. Most activations occurred within 24 hours of surgery, and hypovolemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) hr in cases where fluid boluses were given, compared with 33 (15.5-61.5) hr where they were not (p< 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. CONCLUSIONS: Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on peri-operative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications pre-operatively. This article is protected by copyright. All rights reserved.

Background: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. Objective: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. Methods: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients’ preadmission medications and the number of related adverse events that occurred within 72 hours of admission. Results: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.

OBJECTIVES 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. DESIGN Retrospective case control study. SETTING Level 1 trauma center. MAIN OUTCOME MEASUREMENTS 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. RESULTS 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

Background Venous thromboembolism causes significant morbidity and mortality in patients after total joint arthroplasty. Although network meta-analyses have demonstrated a benefit of various thromboprophylactic agents, there remains a concern in the surgical community regarding the resulting wound complications. There is currently no systematic review of the surgical site bleeding complications of thromboprophylactic agents. The aim of this study was to systematically review the surgical site bleeding outcomes of venous thromboembolism prophylaxis in this population. Methods A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials comparing more than one of low-molecular-weight heparin (LMWH), warfarin, rivaroxaban, apixaban, dabigatran, aspirin, or no pharmacologic treatment in patients after total hip or knee arthroplasty were selected for inclusion. Five meta-analyses were performed to compare LMWH with control, warfarin, apixaban, rivaroxaban, and dabigatran. Results Forty-five randomized controlled trials of 56,730 patients were included. LMWH had a significantly increased relative risk of surgical site bleeding in comparison with control (relative risk, 2.32; 95% confidence interval, 1.40-3.85) and warfarin (1.54; 1.23-1.94). The relative risk of LMWH trended higher than apixaban (1.27; 1.00-1.63) and was similar to rivaroxaban (0.95; 0.74-1.23). Only 1 study reported the risk of surgical site bleeding in LMWH vs dabigatran (5.97; 2.08-17.11). Conclusion LMWH increased the risk of surgical site bleeding compared with control, warfarin. and dabigatran and trended toward an increased risk compared with apixaban. The risk of surgical site bleeding was similar with LMWH and rivaroxaban.

Background Early mobilization is an important therapeutic goal after total knee replacement and total hip replacement. Orthostatic hypotension and orthostatic intolerance can impede mobilization. Midodrine hydrochloride, an orally administered vasoconstrictor, may improve blood pressure and diminish the prevalence of adverse mobilization events. Methods We conducted a pilot change-of-practice study. Two cohorts, each comprising 10 patients managed with total knee replacement and 10 patients managed with total hip replacement, were managed with blood pressure-adjusted midodrine, which was administered 3 times daily for the first 72 hours postoperatively at either a low dose (2.5 or 5 mg) or a higher dose (5 or 10 mg). These patients were then matched with an equivalent preintervention cohort of patients. Results The midodrine protocol was instituted effectively and with high compliance. Hypotension was uncommon across all groups, with the mean lowest systolic blood pressure ranging from 110 to 121 mm Hg. Moreover, adverse mobilization events were uncommon across all groups (prevalence, 9.6% in the control group, 5.6% in the low-dose group, and 2.9% in the high-dose group) (p = 0.046 for the high-dose group versus the control group). A midodrine dose of 10 mg generated a significant mean dose-related systolic blood pressure increase of 14 mm Hg at 2 hours after administration (p Conclusions A dose of 10 mg was found to achieve a significant systolic blood pressure response at 2 hours after administration and, in patients who received higher-dose midodrine, adverse mobilization events appeared less common. Additional investigation with a blinded randomized controlled trial, utilizing 10 mg of midodrine 2 hours before mobilization, would be needed to confirm the efficacy of midodrine therapy. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Complex regional pain syndrome (CRPS) is a term that was introduced twenty years ago by the International Association for the Study of Pain (IASP)1. The intentions behind the nomenclature change were to replace the myriad terms that were used to describe a group of similar conditions (for example, reflex sympathetic dystrophy, Sudeck dystrophy, causalgia, and algodystrophy), to remove the emphasis that names such as reflex sympathetic dystrophy placed on outdated theories about the mechanisms underlying the condition2, and to propose a set of standardized diagnostic criteria. Complex regional pain syndrome is characterized by pain, allodynia, hyperalgesia, edema, changes in skin blood flow, abnormal sudomotor activity, and motor and trophic changes in a limb2,3. Complex regional pain syndrome may develop with or without a specific inciting event such as fracture, peripheral nerve injury, or surgical treatment of a limb3,4. In the orthopaedic clinic, the presence of complex regional pain syndrome may be first evident when plasters and splints are removed, pain medications have been reduced, and patients are commencing …

Background 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. Methods 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. Results 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

Question: Is 50% Partial Weight Bearing Really 50%. Design: Twelve volunteers participated in this prospective, case-control study utilising a portable limb load monitor (NCOunters VIC)

Bone remodelling suppressants like the bisphosphonates reduce bone loss and slow progression of structural decay. As remodelling removes damaged bone, when remodelling suppression is protracted, bone quality may be compromised predisposing to microdamage accumulation and atypical femoral fractures. The aim of this study was to determine whether teriparatide therapy assists in fracture healing and improves bone quality in patients with bisphosphonate associated atypical femoral fractures. A prospective study was conducted involving 14 consecutive patients presenting during 2 years with atypical femoral fracture. All patients were offered teriparatide therapy unless contraindicated. Age and sex matched control subjects without fragility fractures or anti-resorptive treatment were recruited. High resolution peripheral micro-computed tomography (HRpQCT) scans of the distal radius and distal tibia were analysed for their cortical bone tissue mineralisation density using new software (StrAx1.0, StrAxCorp, Australia) at baseline and 6 months after teriparatide. Administration of 20 μg of teriparatide subcutaneously daily for 6 months to 5 of the 14 patients was associated with 2–3 fold increase in bone remodelling markers (p = 0.01) and fracture healing. At the distal radius, the proportion of less densely mineralised bone increased by 29.5% (p = 0.01), and the proportion of older, more densely mineralised bone decreased by 16.2% (p = 0.03). Similar observations were made at the distal tibia. Of the nine patients managed conservatively or surgically, seven had poor fracture healing with ongoing pain, one sustained a contralateral atypical fracture and one had fracture union after 1 year. Teriparatide may assist in healing of atypical fractures and restoration of bone quality.

Purpose.To compare the effectiveness of pulse-lavage brushing followed by hydrogen peroxide–gauze packing with either technique alone or normal-saline irrigation in bone-bed preparation for cemented total hip arthroplasty.Methods.44 fresh-frozen ox femoral canals were prepared for cemented total hip arthroplasty using 4 techniques: normal-saline irrigation, pulse-lavage brushing, hydrogen peroxide–soaked gauze packing, and a combination of the latter 2 techniques. The maximum tensile pull-out force required to separate the prosthesis from the femoral canal was measured as an indicator of the strength of the cement-bone interface.Results.The mean pull-out force to separate the prosthesis from the femoral canal was significantly higher in specimens prepared with pulse-lavage brushing followed by hydrogen peroxide–soaked gauze packing or pulse-lavage brushing alone than those prepared with normal-saline irrigation or hydrogen peroxide–soaked gauze packing alone (pConclusions.Pulse-lavage brushing is more effective at cleansing the femoral canal and increasing mechanical strength at the cement-bone interface than preparation with normal-saline irrigation or hydrogen peroxide–soaked gauze packing.