Outcome of revision total knee arthroplasty with bone allograft in 30 cases

Revision Total Knee Arthroplasty is often complicated by large bone defects in the distal femur and proximal tibia. These defects can be managed in a variety of ways including the use of allograft bone. The purpose of this study was to retrospectively evaluate the clinical outcome of revision total knee arthroplasty cases where allograft bone was used. Thirty revision TKA's (27 patients) performed between 1994 and 2009 were followed for a mean of 5 years (1- 14 years). Preoperative bone defects were classified using the Anderson Orthopaedic Research Institute classification system. Patient follow-up entailed calculation of the Knee Society Score and radiological assessment of the revision joint replacement in addition to review of complications. Kaplan Meier analysis predicted survivorship at 5 years as 93%, with further revision surgery as end point. The average Knee Society Score was 76.4, with 19 (63%) of knees scoring "excellent" results, 4 (14%) "good", 1 (3%) "fair" and 6 (20%) were "poor". The overall complication rate was 23.3%. Radiological lucency was demonstrated on recent radiographs for one patient. Three knees were re-revised at 1 year, 6 years and 8 years respectively. Our study demonstrates promising short to medium term results with the use of allograft bone in revision total knee replacement presenting with significant bone loss

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

The use of structural bone allografts in revision total hip arthroplasty: biology and clinical applications

Techniques using structural allografts are useful when the orthopaedic surgeon is faced with large segmental and sometimes cavitary acetabular defects, or segmental defects affecting the proximal femoral metaphysis. On the acetabular side this technique usually involves bolting the graft to the ileum, followed by insertion of a cementless acetabular component if the allograft supports less than 40% of its circumference or the use of a cage when it is estimated that the allograft will support more than 40% of a cup circumference. On the femoral side, the technique involves the use of a composite consisting of a proximal femoral allograft and cemented femoral prosthesis. Use of these techniques is appealing, especially in young patients, because of its potential to restore bone stock. The present chapter will discuss the biology, indications, techniques and the results with the use of structural allografts in cases of revision hip arthroplasty

The use of structural allograft composites for bone stock reconstruction in revision total knee arthroplasty

Structural allograft composites can be used to reconstruct large bony defects of the distal femur and proximal tibia during revision total knee arthroplasty (TKA). The technique involves the use of a composite consisting of a distal femur or proximal tibia allograft and a stemmed prosthesis which is cemented to the allograft. The use of these techniques is appealing, especially in young patients, because of the potential to restore bone stock. The present chapter discusses indications, techniques and results with the use of structural allograft composites in complex cases of revision (TKA) presenting with severe loss of bone

Cascading Mentorship:Designing a Support Tool for Patients with Ventricular Assist Devices

A ventricular assist device (VAD) is a surgically implanted mechanical pump attached to the heart to assist its function in patients with advanced heart failure. This paper investigates the current state of training being provided to VAD patients and caregivers, and whether it adequately prepares them for the VAD lifestyle. The study consisted of a literature review, a content analysis and interviews conducted with stakeholder representatives. A co-design process led to the development a holistic interactive prototype that was evaluated by one VAD caregiver, one VAD biomedical engineer, and one VAD surgeon. Four key themes emerged from the research examining the VAD patient and caregiver training experience: (i) uncertainty, (ii) misinformation, (iii) gratitude, and (iv) preparation. Five overarching themes emerged as design recommendations: (1) artificial onboarding, (2) contextual empathy, (3) ongoing support, (4) physician connectivity, and (5) emergency scenarios. Findings suggest the need to focus on not just the patient, but equally on the VAD caregiver. Design opportunities include the optimisation of both training tools and VAD communication relating to emergency scenario preparation