Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

A quality improvement project decreases incidence of pulmonary embolism following arthroplasty.

OBJECTIVE: To develop a quality improvement initiative to reduce the incidence of pulmonary embolism (PE) following elective lower extremity joint replacement surgery. METHODS: 866 Patients undergoing a total knee or total or partial hip replacement surgery at a from 2014 to 2016 were included in this prospective pre-post interventional study. RESULTS: There were 13 PE's before the intervention and 2 after the intervention. The incidence of PE was significantly higher prior to the intervention (2.8% vs. 0.7%; p = 0.044). CONCLUSIONS: Our results suggest that our bundle of interventions was successfully implemented and helped to reduce the incidence of pulmonary embolism following surgery.

Defining an International Standard Set of Outcome Measures for Patients With Hip or Knee Osteoarthritis: Consensus of the International Consortium for Health Outcomes Measurement Hip and Knee Osteoarthritis Working Group.

OBJECTIVE: To define a minimum Standard Set of outcome measures and case-mix factors for monitoring, comparing, and improving health care for patients with clinically diagnosed hip or knee osteoarthritis (OA), with a focus on defining the outcomes that matter most to patients. METHODS: An international working group of patients, arthroplasty register experts, orthopedic surgeons, primary care physicians, rheumatologists, and physiotherapists representing 10 countries was assembled to review existing literature and practices for assessing outcomes of pharmacologic and nonpharmacologic OA therapies, including surgery. A series of 8 teleconferences, incorporating a modified Delphi process, were held to reach consensus. RESULTS: The working group reached consensus on a concise set of outcome measures to evaluate patients' joint pain, physical functioning, health-related quality of life, work status, mortality, reoperations, readmissions, and overall satisfaction with treatment result. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were defined. Annual outcome measurement is recommended for all patients. CONCLUSION: We have defined a Standard Set of outcome measures for monitoring the care of people with clinically diagnosed hip or knee OA that is appropriate for use across all treatment and care settings. We believe this Standard Set provides meaningful, comparable, and easy to interpret measures ready to implement in clinics and/or registries globally. We view this set as an initial step that, when combined with cost data, will facilitate value-based health care improvements in the treatment of hip and knee OA.

Cartilage health in high tibial osteotomy using dGEMRIC: Relationships with joint kinematics.

PURPOSE: The aims of this study are to determine how opening-wedge high tibial osteotomy (HTO) affects cartilage health in the tibiofemoral (TF) joint and patella, and to explore relationships between TF and patellofemoral (PF) joint kinematics and cartilage health in HTO. METHODS: 14 knees (13 subjects) with medial TF osteoarthritis (OA) were examined before HTO and 6 and 12 months after HTO using delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) to evaluate cartilage health at the TF joint and patella. They were also examined using a validated 3D MR knee kinematics measurement to obtain 11 rotations and translations at both TF and PF joints. RESULTS: No statistically significant differences in overall TF or patellar dGEMRIC score were found at 6 or 12 months after HTO. However three subjects had large decreases (mean 105 ms) in TF dGEMRIC at 6 months that recovered at 12 months. Kinematics for these subjects were compared to subjects who did not have decreases in TF dGEMRIC at 6 months (n=5). Differences were observed between groups with HTO in anterior and proximal tibial translation (mean differences 3.05 mm and 1.35 mm), and patellar flexion (mean difference 3.65°). These changes were consistent between 6 and 12 months, despite recovery of TF dGEMRIC values. CONCLUSIONS: We did not find significant differences in TF or patellar dGEMRIC before and after HTO with all subjects, however there were differences in kinematics between subjects who had a decrease in TF dGEMRIC at 6 months and those who did not. This suggests a link between joint kinematics and cartilage health in HTO. CLINICAL RELEVANCE: The effect of opening-wedge high tibial osteotomy on cartilage GAG concentration may be linked to specific changes in knee kinematics following surgery.

Automated cuff occlusion pressure effect on quality of operative fields in foot and ankle surgery: a randomized prospective study.

BACKGROUND: Limb occlusion pressure, which is present when blood flow ceases, has not had a practical method described for attainment. An automated tourniquet system was modified to set tourniquet pressure based on measurement of limb occlusion pressure (LOP). In this single surgeon randomized prospective study, the effectiveness of this system was assessed on patients undergoing foot and ankle surgery. MATERIALS AND METHODS: Two hundred forty-four patients were randomized to the study group of automated pressure (n = 112) or to the control group (n = 132). The primary outcome measure was tourniquet pressure used for either group. Secondary measures included the time to set the pressure and number of patients failing LOP measurement. The tourniquet field was assessed intraoperatively and postoperatively in a blinded manner. RESULTS: The tourniquet pressure was significantly lower in the study group at 198.5 ± 20.2 mmHg compared to 259.6 ± 4.4 in the control group (p < 0.001). The time to measure the LOP was 20 ± 6 seconds. Six patients failed to be measured. The quality of the surgical field was judged to be better in the study group based on all three methods of assessment. CONCLUSION: LOP measurement was a practical way of setting tourniquet pressures for limb surgery. The automated pressure averages were lower than those routinely used by most surgeons for thigh tourniquets.