A multi-disciplinary program for opioid sparse arthroplasty results in reduced long-term opioid consumption: a four year prospective study

Published online: 29 March 2023Introduction: The current opioid epidemic poses patient safety and economic burdens to healthcare systems worldwide. Postoperative prescriptions of opioids contribute, with reported opioid prescription rates following arthroplasty as high as 89%. In this multi-centre prospective study, an opioid sparing protocol was implemented for patients undergoing knee or hip arthroplasty. The primary outcome is to report our patient outcomes in the context of this protocol, and to examine the rate of opioid prescription on discharge from our hospitals following joint arthroplasty surgery. This is possibly associated with the efficacy of the newly implemented Arthroplasty Patient Care Protocol. Methods: Over three years, patients underwent perioperative education with the expectation to be opioid-free after surgery. Intraoperative regional analgesia, early postoperative mobilisation and multimodal analgesia were mandatory. Long-term opioid medication use was monitored and PROMs (Oxford Knee/Hip Score (OKS/OHS), EQ-5D-5 L) were evaluated pre-operatively, and at 6 weeks, 6 months and 1 year postoperatively. Primary and secondary outcomes were opiate use and PROMs at different time points. Results: A total of 1,444 patients participated. Two (0.2%) knee patients used opioids to one year. Zero hip patients used opioids postoperatively at any time point after six weeks (p < 0.0001). The OKS and EQ-5D-5 L both improved for knee patients from 16 (12–22) pre-operatively to 35 (27–43) at 1 year postoperatively, and 70 (60–80) preoperatively to 80 (70–90) at 1 year postoperatively (p < 0.0001). The OHS and EQ-5D-5 L both improved for hip patients from 12 (8–19) preoperatively to 44 (36–47) at 1 year postoperatively, and 65 (50–75) preoperatively to 85 (75–90) at 1 year postoperatively (p < 0.0001). Satisfaction improved between all pre- and postoperative time points for both knee and hip patients (p < 0.0001). Conclusions: Knee and hip arthroplasty patients receiving a peri-operative education program can effectively and satisfactorily be managed without long-term opioids when coupled with multimodal perioperative management, making this a valuable approach to reduce chronic opioid use.D-Yin Lin, Anthony J. Samson, Freeda D, Mello, Brigid Brown, Matthew G. Cehic, Christopher Wilson, Hidde M. Kroon and Ruurd L. Jaarsm

Evaluation of the EQ-5D-5L, EQ-VAS stand-alone component and Oxford knee score in the Australian knee arthroplasty population utilising minimally important difference, concurrent validity, predictive validity and responsiveness

Published online: 10 May 2023Purpose: To evaluate the Oxford Knee Score (OKS), EQ-5D-5L utility index and EQ-5D visual analogue scale (EQ-VAS) for health-related quality of life outcome measurement in patients undergoing elective total knee arthroplasty (TKA) surgery. Methods: In this prospective multi-centre study, the OKS and EQ-5D-5L index scores were collected preoperatively, six weeks (6w) and six months (6 m) following TKA. The OKS, EQ-VAS and EQ-5D-5L index were evaluated for minimally important difference (MID), concurrent validity, predictive validity (Spearman's Rho of predicted and observed values from a generalised linear regression model (GLM)), responsiveness (effect size (ES) and standard response mean (SRM)). The MID for the individual patient was determined utilising two approaches; distribution-based and anchor-based. Results: 533 patients were analysed. The EQ-5D-5L utility index showed good concurrent validity with the OKS (r = 0.72 preoperatively, 0.65 at 6w and 0.69 at 6 m). Predictive validity for the EQ-5D-5L index was lower than OKS when regressed. Responsiveness was large for all fields at 6w for the EQ-5D-5L and OKS (EQ-5D-5L ES 0.87, SRM 0.84; OKS ES 1.35, SRM 1.05) and 6 m (EQ-5D-5L index ES 1.31, SRM 0.95; OKS ES 1.69, SRM 1.59). The EQ-VAS returned poorer results, at 6w an ES of 0.37 (small) and SRM of 0.36 (small). At 6 m, the EQ-VAS had an ES of 0.59 (moderate) and SRM of 0.47 (small). It, however, had similar predictive validity to the OKS, and better than the EQ-5D-5L index. MID determined using anchor approach, was shown that for OKS at 6 weeks it was 8.84 ± 9.28 and at 6 months 13.37 ± 9.89. For the EQ-5D-5L index at 6 weeks MID was 0.23 ± 0.39, and at 6 months 0.26 ± 0.36. Conclusions: The EQ-5D-5L index score and the OKS demonstrate good concurrent validity. The EQ-5D-5L index demonstrated lower predictive validity at 6w, and 6 m than the OKS, and both PROMs had adequate responsiveness. The EQ-VAS had poorer responsiveness but better predictive validity than the EQ-5D-5L index. This article includes MID estimates for the Australian knee arthroplasty population.D-Yin Lin, Tim Soon Cheok, Billingsley Kaambwa, Anthony J. Samson, Craig Morrison, Teik Chan, Hidde M. Kroon and Ruurd L. Jaarsm

Short-term difference only in reported outcomes (PROMs) after anterior or posterior approach to total hip arthroplasty: a 4-year prospective multi-centre observational study

Published online: 17 February 2023Background: The direct anterior approach (DAA) in total hip arthroplasty (THA) may demonstrate better functional recovery compared to the posterior approach (PA). Methods: In this prospective multi-centre study, patient-related outcome measures (PROMs) and length of stay (LOS) were compared between DAA and PA THA patients. The Oxford Hip Score (OHS), EQ-5D-5L, pain and satisfaction scores were collected at four perioperative stages. Results: 337 DAA and 187 PA THAs were included. The OHS PROM was significantly better in the DAA group at 6 weeks post-operatively (OHS: 33 vs. 30, p = 0.02, EQ-5D-5L: 80 vs. 75, p = 0.03), but there were no differences at 6 months and at 1 year. EQ-5D-5L scores were similar between both groups at all time points. LOS as inpatient was significantly different, in favour of DAA [median 2 days (IQR 2–3) vs. PA 3 (IQR 2–4), p ≤ 0.0001]. Conclusions: Patients undergoing DAA THA have shorter LOS and report better short-term Oxford Hip Score PROMs at 6 weeks, but DAA did not convey long-term benefits over PA THA.D, Yin Lin, Anthony J. Samson, Matthew G. Cehic, Brigid Brown, Billingsley Kaambwa, Christopher Wilson, Hidde M. Kroon and Ruurd L. Jaarsm

Clockwise torque results in higher reoperation rates in left-sided femur fractures

Purpose: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left-versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). Materials and methods: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. Results: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (& alpha;=0.05). Conclusion: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (post-operative) weightbearing may lead to higher reoperation rates. Level of evidence: Therapeutic level II.Orthopaedics, Trauma Surgery and Rehabilitatio

Rotational Malalignment after fractures of the femur.

Contains fulltext : 19538.pdf (publisher's version ) (Open Access)Rotational malalignment is an important complication of intramedullary nailing for femoral shaft fractures. The deformity is established during the operation, indicating inadequate reduction of the fracture. Little was known about the incidence and clinical implications of femoral malrotation. In a series of 76 patients we found 28% to have rotational malalignment ( 15 ). Patients complain about problems with more demanding activities, like practicing sports. The incidence of malrotation was independent of the type of femoral nail (GK or AO) used or the location of the fracture. External rotational deformities cause significantly more symptoms than internal rotational deformities. Rotational malalignment is usually measured clinically or by computed tomography (CT). CT is currently the method of choice. Our study reveals that the accuracy of the clinical measurements is very poor ( 20 ). Also the accuracy of CT determined rotational malalignment of the femur is questionable. Differences between two measurements of one observer can be 10.8 and between two measurements of different observers 15.6 . The inaccuracy in measuring a CT image is mostly determined by the inaccuracy in drawing the line through the femoral neck. All patients with femoral malrotation tend to compensate towards a normal value of foot rotation, relative to the femoral torsion present. The major part of this compensation takes place at hip level. Patients with an external malrotation experience more difficulties compensating, than patients with an internal malrotation. In vitro, rotational malalignment is completely avoided by using the profile of the contralateral lesser trochanter as a reference. Rotations only up to 4 (2.2 1.5 ) were measured. The American Medical Association's Guide to the Evaluation of permanent Impairment does not differ between external and internal malrotation of the femur when evaluating whole person impairment. This is incorrect and the American Medical Association should consider changing this in their guidelines.KUN Katholieke Universiteit Nijmegen, 29 november 2004Promotores : Kampen, A. van, Duysens, J.E.J. Co-promotores : Verdonschot, N.J.J., Biert, J.136 p

Rotational Malalignment after fractures of the femur.

Rotational malalignment is an important complication of intramedullary nailing for femoral shaft fractures. The deformity is established during the operation, indicating inadequate reduction of the fracture. Little was known about the incidence and clinical implications of femoral malrotation. In a series of 76 patients we found 28% to have rotational malalignment ( 15 ). Patients complain about problems with more demanding activities, like practicing sports. The incidence of malrotation was independent of the type of femoral nail (GK or AO) used or the location of the fracture. External rotational deformities cause significantly more symptoms than internal rotational deformities. Rotational malalignment is usually measured clinically or by computed tomography (CT). CT is currently the method of choice. Our study reveals that the accuracy of the clinical measurements is very poor ( 20 ). Also the accuracy of CT determined rotational malalignment of the femur is questionable. Differences between two measurements of one observer can be 10.8 and between two measurements of different observers 15.6 . The inaccuracy in measuring a CT image is mostly determined by the inaccuracy in drawing the line through the femoral neck. All patients with femoral malrotation tend to compensate towards a normal value of foot rotation, relative to the femoral torsion present. The major part of this compensation takes place at hip level. Patients with an external malrotation experience more difficulties compensating, than patients with an internal malrotation. In vitro, rotational malalignment is completely avoided by using the profile of the contralateral lesser trochanter as a reference. Rotations only up to 4 (2.2 1.5 ) were measured. The American Medical Association's Guide to the Evaluation of permanent Impairment does not differ between external and internal malrotation of the femur when evaluating whole person impairment. This is incorrect and the American Medical Association should consider changing this in their guidelines

Rotational malalignment after fractures of the femur.

Item does not contain fulltex

[Limb-length measurements using wooden boards: an accurate and experience-independent method]

Item does not contain fulltextOBJECTIVE: To determine the precision and reliability of the indirect limb-length measurement, and the inter-observer variance between doctors differing in level of experience. DESIGN: Descriptive. METHOD: Indirect limb-length measurement by placing 0.5 cm-thick wooden boards under the foot of the shorter leg until the difference in length was corrected, was performed by 3 observers differing in experience (medical student, resident and orthopaedic surgeon) on 66 patients with unilateral femoral-shaft fractures treated with a femoral nail. The group of patients consisted of 51 men and 15 women with a median age of 30 years (range: 18-90). In total 17 observers participated and 177 limb-length measurements were performed. The measurements obtained were compared with limb-length measurements obtained by orthoradiograms of the entire leg. RESULTS: Of the 177 indirect limb-length measurements, 144 (81%) differed by 0-1.0 cm compared with the limb length obtained by orthoradiogram. There was no statistically significant difference in the limb-length measurements obtained by the three groups of observers with different experience levels. There was a certain degree of correlation between values measured by medical students and residents (r = 0.7). When comparing the measurements carried out by staff members with those of residents and medical students, respectively, a lower degree of correlation was found (r = 0.6 and 0.5, respectively). CONCLUSION: Indirect limb-length measurement with wooden boards was accurate. Experience did not play an essential role

K-wire position in tension-band wiring technique affects stability of wires and long-term outcome in surgical treatment of olecranon fractures.

Item does not contain fulltextBACKGROUND: Tension-band wiring (TBW) has been accepted as the treatment of choice for displaced olecranon fractures. The aim of this study was to examine the effect of K-wire position on instability of the K-wires in relation to local complications and radiological and clinical long-term outcome. METHODS: We reviewed the early follow-up of 59 patients (mean age, 60 years) who underwent TBW osteosynthesis for displaced olecranon fractures. Follow-up information was available from medical records and radiographs. The main outcome measurements were proximal migration of the wires, gap, step, range of motion, and complications. Long-term follow-up included 21 patients (mean age, 58 years). Follow-up was available from a clinical visit and a radiograph. Visual Analogue Scale (VAS), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), EuroQol-5D (EQ-5D), and Broberg and Morrey osteoarthritis scores were obtained. RESULTS: Seventy-eight percent of the patients treated with intramedullary K-wires were found to have instability of K-wires, compared to 36% in the patients treated with transcortical K-wires. Patients with instability of the K-wires tend to develop osteoarthritis more often. There is a better functional outcome in patients where the osteosynthetic material is removed. CONCLUSION: Instability of K-wires after TBW is more common after intramedullary placement of the wires resulting in proximal migration of the K-wires and gap appearance. There was a tendency of more osteoarthritis in the group of patients where instability of K-wires was identified. We would recommend the use of transcortical placed wires, as well as to have a low threshold in removing the implants.1 maart 201