Health Technology Assessment for Fast-Track Elective Knee and Hip Arthroplasty in a High-Volume Orthopaedic Hospital in Italy.

Objective: The objective of the analysis presented is to assess the efficacy of a fast-track pathway for elective hip and knee arthroplasty, compared to the traditional approach, adopted within a research hospital located in Milan (Italy), in terms of length of stay reduction and related direct medical costs. Methods: A monocentric observational retrospective study was implemented considering adult subjects who underwent elective primary total hip or knee replacement, with a diagnosis of primary or secondary osteoarthritis. Exclusion criteria were subjects admitted via emergency department, subjects undergoing knee or hip replacement because of fractures or prosthesis revision. The analysis compared the length of stay and the direct medical costs, assuming the hospital perspective, of subjects admitted in the pre-fast-track period (years 2016/2017) and during the fast-track period (years 2018/2019). Results: Knee replacement mean costs are 5,599 € (±1,158.3 €) in the pre-fast-track period and 4,487 € (±978.4 €) in the fast-track period (-1,112 €; -19.9%). Hip replacement mean costs in the pre-fast-track period are 5,364 € (±1,037.2 €) and 4,450 € (±843.7 €) in the fast-track period (-914 €; -17.0%). The adoption of fast-track pathway led to a statistically significant decrease of days of hospitalization of -2.8 (-37.6%) in knee replacement and of -2.9 (-39.2%) in hip replacement. Conclusion: The fast-track pathway adopted proved to be effective, reducing patients' length of stay, and sustainable and efficient, reducing direct medical costs, for both elective hip and knee replacement surgeries.

Connexin 43 Modulation in Human Chondrocytes, Osteoblasts and Cartilage Explants: Implications for Inflammatory Joint Disorders.

Connexin 43 (Cx43) is crucial for the development and homeostasis of the musculoskeletal system, where it plays multifaceted roles, including intercellular communication, transcriptional regulation and influencing osteogenesis and chondrogenesis. Here, we investigated Cx43 modulation mediated by inflammatory stimuli involved in osteoarthritis, i.e., 10 ng/mL Tumor Necrosis Factor alpha (TNFα) and/or 1 ng/mL Interleukin-1 beta (IL-1ß), in primary chondrocytes (CH) and osteoblasts (OB). Additionally, we explored the impact of synovial fluids from osteoarthritis patients in CH and cartilage explants, providing a more physio-pathological context. The effect of TNFα on Cx43 expression in cartilage explants was also assessed. TNFα downregulated Cx43 levels both in CH and OB (-73% and -32%, respectively), while IL-1ß showed inconclusive effects. The reduction in Cx43 levels was associated with a significant downregulation of the coding gene GJA1 expression in OB only (-65%). The engagement of proteasome in TNFα-induced effects, already known in CH, was also observed in OB. TNFα treatment significantly decreased Cx43 expression also in cartilage explants. Of note, Cx43 expression was halved by synovial fluid in both CH and cartilage explants. This study unveils the regulation of Cx43 in diverse musculoskeletal cell types under various stimuli and in different contexts, providing insights into its modulation in inflammatory joint disorders.

Starvation and Inflammation Modulate Adipose Mesenchymal Stromal Cells' Molecular Signature.

Mesenchymal stromal cells (MSCs) and their released factors (secretome) are intriguing options for regenerative medicine approaches based on the management of inflammation and tissue restoration, as in joint disorders like osteoarthritis (OA). Production strategy may modulate cells and secretome fingerprints, and for the latter, the effect of serum removal by starvation used in clinical-grade protocols has been underestimated. In this work, the effect of starvation on the molecular profile of interleukin 1 beta (IL1ß)-primed adipose-derived MSCs (ASCs) was tested by assessing the expression level of 84 genes related to secreted factors and 84 genes involved in defining stemness potential. After validation at the protein level, the effect of starvation modulation in the secretomes was tested in a model of OA chondrocytes. IL1ß priming in vitro led to an increase in inflammatory mediators' release and reduced anti-inflammatory potential on chondrocytes, features reversed by subsequent starvation. Therefore, when applying serum removal-based clinical-grade protocols for ASCs' secretome production, the effects of starvation must be carefully considered and investigated.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

BACKGROUND: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success. METHODS: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices. RESULTS: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care. CONCLUSIONS: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.

May the 4th be with you: mixed-methods best-evidence synthesis on 4th-generation alumina-zirconia ceramic bearings in total hip arthroplasty.

Purpose: To assess utility, benefits, and risks of 4th-generation alumina-zirconia ceramic pairings in elective total hip arthroplasty (THA). Methods: A comprehensive mixed-methods best-evidence synthesis using data from systematic reviews, randomized controlled trials (RCTs), prospective and retrospective cohort studies, as well as joint replacement registries, was conducted to estimate overall revision and survival rates, periprosthetic infection, bearing fractures, and noise phenomena with 4th-generation alumina-zirconia ceramic versus other tribological couplings in elective THA. The systematic review part across multiple databases was registered with PROSPERO (CRD42023418076), and individual study data were extracted for statistical re-analysis. Results: Twenty overlapping systematic reviews, 7, 17, and 8 references from RCTs, cohort studies, and joint replacement registries form the basis of this work. According to current best evidence, it is (i) 15-33 times more likely that 4th-generation alumina-zirconia pairings avoid a revision for infection than causing a revision for audible noise, (ii) 38-85 times more likely that 4th-generation alumina-zirconia pairings avoid a revision for infection than causing a revision for ceramic head fractures, and (iii) three to six times more likely that 4th-generation alumina-zirconia pairings avoid a revision for infection than cause a revision for ceramic liner fractures. Conclusion: Fourth-generation alumina-zirconia pairings in THA show a favorable benefit-risk ratio, with rare compound-specific adverse events and complications significantly outbalanced by long-term advantages, such as a markedly lower incidence of revision for infection.

Early functional recovery outcomes and return to work after primary total hip arthroplasty: a novel patient reported outcomes questionnaire.

PURPOSE: Clinical and patient reported outcomes are often collected before and after the procedure to benchmark and study outcomes for patients. These outcomes and scores are useful for tracking patient outcomes after surgery, however, the fact that these commonly used measures typically provide information about a patient's level of pain and function at a single point in time is a limitation. METHODS: We present early functional recovery and return to work outcomes after primary THA from a novel questionnaire administered in a global, multi-center, prospective clinical study. RESULTS: By 6 and 12 weeks post-op, a large proportion of study subjects were able to perform functional recovery outcomes after their THA: walk without an aid (74%; 94%); drive (76%; 97%); basic activities of daily living (94%; 99%); perform light household duties (91%; 96%); perform moderate-to-heavy household duties (54%; 86%); go up and down a flight of stairs (92%; 99%); put on socks/stockings (77%; 93%); bend down to pick up an object from the floor (87%; 97%); stand up from a chair (96%; 99%); perform leisure recreational activities (54%; 84%); perform primary goal identified pre-THA (69%; 86%). 60% were able to return to work by 12 weeks post-op. These questions showed strong association with the Forgotten Joint Score. CONCLUSION: Excellent patient reported early functional recovery outcomes and satisfaction were observed at 6- and 12-weeks post-op in this cohort and is the first reported data using a novel PRO. CLINICAL TRIAL REGISTRATION: NCT03189303, registered June 14, 2017.

Cartilage responses to inflammatory stimuli and adipose stem/stromal cell-derived conditioned medium: Results from an ex vivo model.

Introduction: Osteoarthritis (OA), a chronic inflammatory joint disorder, still lacks effective therapeutic interventions. Consequently, the development of convenient experimental models is crucial. Recently, research has focused on the plasticity of Mesenchymal Stem/stromal Cells, particularly adipose-derived ones (ASCs), in halting OA progression. This study investigates the therapeutic potential of a cell-free approach, ASC-derived conditioned medium (CM), in reversing cytokine-induced OA markers in an ex vivo model of human cartilage explants. Methods: 4 mm cartilage punches, derived from the femoral heads of patients undergoing total hip replacement, were treated with 10 ng/ml TNFα, 1 ng/ml IL-1ß, or a combination of both, over a 3-day period. Analysis of OA-related markers, such as MMP activity, the release of NO and GAGs, and the expression of PTGS2, allowed for the selection of the most effective inflammatory stimulus. Subsequently, explants challenged with TNFα+IL-1ß were exposed to CM, consisting of a pool of concentrated supernatants from 72-h cultured ASCs, in order to evaluate its effect on cartilage catabolism and inflammation. Results: The 3-day treatment with both 10ng/ml TNFα and 1ng/ml IL-1ß significantly increased MMP activity and NO release, without affecting GAG release. The addition of CM significantly downregulated the abnormal MMP activity induced by the inflammatory stimuli, while also mildly reducing MMP3, MMP13, and PTGS2 gene expression. Finally, SOX9 and COL2A1 were downregulated by the cytokines, and further decreased by CM. Conclusion: The proposed cartilage explant model offers encouraging evidence of the therapeutic potential of ASC-derived CM against OA, and it could serve as a convenient ex vivo platform for drug screening.

Increased adherence to influenza vaccination among Palermo family pediatricians: a study on safety and compliance of qLAIV vaccination.

BACKGROUND: Influenza represents a serious public health threat, especially for the management of severe cases and complications of the disease, requiring the implementation of control measures. We aimed to assess the acceptance and impact of qLAIV vaccination among a representative sample of family paediatricians (FPs) operating in Palermo Local Health Authority (LHA). To this end we evaluated vaccination coverage rates, comparing it with that observed in Sicilian context, while actively monitoring possible adverse reactions and their severity. METHODS: An observational descriptive non-controlled study was conducted in two phases, from September 2022 to June 2023. The first phase involved a formative and educational intervention with a pre-intervention questionnaire to assess the knowledge and attitudes of FPs on paediatric influenza vaccination. The second phase consisted of an active surveillance on qLAIV safety and acceptance among the paediatric population assisted by the participating FPs, from October 2022 to April 2023. Frequencies, chi-squared tests, and comparisons statistics were performed using Stata/MP 14.1. RESULTS: The overall coverage rate among the paediatric population involved in the intervention was 13.2%, with an I.M./qLAIV ratio of vaccine administered of 1/4.25. This coverage rate was significantly higher (p-value <0.001) when compared to the average values reported in the population under the Palermo Local Health Authority (LHA) (6.7%) and in the entire Sicily (5.9%). Adverse events in the qLAIV group were mild, with only 3.3% experiencing them, primarily presenting as a feverish rise (3.2%). No severe adverse reaction was reported. CONCLUSIONS: The educational intervention significantly raised paediatric influenza vaccination rates among the participating FPs, and in general improved influenza vaccination coverage rates in the Palermo's LHU. Minimal, non-serious adverse events underscored the vaccine's safety. Training sessions ensured paediatricians stayed informed, enabling them to provide comprehensive information to parents for secure and informed vaccination decisions in their practices.

US-Guided Interventional Procedures for Total Hip Arthroplasty.

In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.

MRI of total hip arthroplasty: technical aspects and imaging findings.

Total hip arthroplasty (THA) is the best surgical approach for treating advanced hip degeneration, providing pain relief, and improved function in most cases. In the past, MR imaging quality has been highly compromised by in-plane distortions, inadequate fat saturation, and other artifacts due to metal components of THA. Technological advancements have made pathologic conditions, which were previously hidden by periprosthetic artifacts, outstanding features due to the optimization of several sequences. To date, several short and long-term complications involving bony and soft-tissue structures may be detected through magnetic resonance imaging (MRI). The use of MRI with adapted sequences and protocols may drastically reduce artifacts thereby providing essential pre-operative elements for planning revision surgery of failed THA. This review has the purpose of conveying new insights to musculoskeletal radiologists about the techniques to suppress metal-related artifacts and the hallmark MRI findings of painful THA. CRITICAL RELEVANCE STATEMENT: Advancements in metal-suppression have given radiologists the opportunity to play an emerging role in THA management. This article provides technical and imaging insights into challenges that can be encountered in cases of THA, which may present complications and characteristic imaging findings. KEY POINTS: Imaging total hip arthroplasty requires adapted MRI protocol and awareness of the common complications. We have reported the available metal-suppression sequences for evaluating total hip arthroplasty. Many structures and conditions should be considered when dealing with painful aseptic or septic arthroplasty.

Accuracy of cup placement compared with preoperative surgeon targets in primary total hip arthroplasty using standard instrumentation and techniques: a global, multicenter study.

BACKGROUND: Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures is in question. Several studies have raised concerns about the benefits of using the Lewinnek safe zone as a predictor of success. In this study we elected to use prospective surgeon targets as the basis for comparison to see how successful surgeons are positioning their cup using standard instruments and techniques. METHODS: A prospective, global, multicenter study was conducted. Cup positioning success was defined as a composite endpoint. Both cup inclination and version needed to be within 10° of the surgeon target to be considered a success. Radiographic analysis was conducted by a third-party reviewer. RESULTS: In 170 subjects, inclination, target versus actual, was 44.8° [standard deviation (SD 0.9°)] and 43.1° (SD 7.6°), respectively (p = 0.0029). Inclination was considered successful in 84.1% of cases. Mean version, target versus actual, was 19.4° (SD 3.9°) and 27.2° (SD 5.6°), respectively (p < 0.0001). Version was considered successful in 63.4% of cases, and combined position (inclination and version) was considered successful in 53.1%. CONCLUSION: This study shows that with traditional methods of placing the cup intraoperatively, surgeons are only accurate 53.1% of the time compared with a predicted preoperative plan. This study suggests that the inconsistency in cup positioning based on the surgeon's planned target is potentially another important variable to consider while using a mechanical guide or in freehand techniques for cup placement in THA. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, NCT03189303.

Ultrasound-Guided Hip Injections with High Density Hyaluronic Acid: Outcome at One Year Follow Up.

Background: The ultrasound-guided viscosupplementation of the hip joint with hyaluronic acid (HA) is considered a standard procedure among the conservative treatments for hip arthritis. The aim of this study was to evaluate the clinical benefit and the incidence of adverse events of the technique in an observational study at one year follow up. Methods: We evaluated a consecutive series of 85 patients with a diagnosis of symptomatic arthritis who underwent intra-articular ultrasound-guided hyaluronic acid injections. The scales used for evaluation were modified Harris Hip Score (mHHS), WOMAC (Western Ontario and McMaster University), and Hip Outcome Score (HOS) with subscale Sport (HOSs), for pain the Visual Analogic Scale (VAS). The patients were classified according to Tonnis' radiological classification of arthritis (range 0-3): 20 patients (grade 0), 32 (grade 1), 18 (grade 2), 15 (grade 3). Results: At last follow up, all the scales increased: mHHS from 59.35 to 82.1, HOS from 69.45 to 78.53, HOss from 47.4 to 58.11, VAS from 6.09 to 3.97, WOMAC from 33.2 to 31.5 (p < 0.05 for all the parameters); the results were elaborated with GraphPad Prism v5.0 (Prism Software La Jolla, CA, USA) using Wilcoxon's test. A total of 13 patients out of 85 needed arthroplasty, all classified as Tonnis grade 3. No serious adverse events were noted due to the procedure. Conclusions: Based on our findings, indication for the use of hyaluronic acid is limited to patients with mild to moderate arthritis. Patients in advanced arthritis refusing replacement surgery and asking for this treatment should be informed about the poor results of the technique even in the short term.

There is a correlation between nutritional status, Self-Rated Health and Life Satisfaction? Evidence from 2018 Health Behaviour in School-aged Children cross sectional study in a sample of Italian adolescents living in Tuscany Region.

Background: Overweight has been associated with several social and phycological problems and is perceived as one of the major health care challenges to focus on in the future. The purpose of the study is to investigate the correlations among nutritional status, assessed by the Body Mass Index, the perception of one's own health status and Life Satisfaction, detected in Italian adolescents living in Tuscany Region, and to investigate the influence of gender on them. Methods: A statistically representative sample of 2760 Tuscan adolescents aged 11, 13 and 15 was involved in the 2018 Health Behaviours at School-aged Children survey. The participants were divided into three nutritional status class: underweight, normal weight and overweight (overweight + obese). Results: The results show that there is a statistically significant difference in all categories between boys and girls aged 13 and 15 years; in girls aged 11 and 13 years, the Life Satisfaction of the overweight group is statistically lower than that of normal and underweight groups; Self-Rated Health is statistically lower in all age groups for overweight individuals compared to normal weight children, except for 11-year-old females. Conclusions: Viewing the psychosocial problems related to overweight, more attention and care must be placed on adolescents to ensure their healthier development.

Using Macrophage Polarization in Human Platelet Lysate to Test the Immunomodulatory Potential of Cells for Clinical Use.

Macrophage-based co-cultures are used to test the immunomodulatory function of candidate cells for clinical use. This study aimed to characterize a macrophage polarization model using human platelet lysate (hPL) as a GMP-compliant alternative to Fetal Bovine Serum (FBS). Primary human monocytes were differentiated into unpolarized (M0) or polarized (M1, M2a, and M2c) macrophages in an hPL- or FBS-based medium. The protein secretion profiles and expression of phenotypic markers (CD80 for M1, CD206 for M2a, and CD163 for M2c) were analyzed. Subsequently, chondrocytes were tested in an hPL-based co-culture model to assess their immunomodulatory function in view of their possible use in patients with osteoarthritis. The results showed similar marker regulation between hPL and FBS cultures, but lower basal levels of CD206 and CD163 in hPL-cultured macrophages. Functional co-culture experiments with chondrocytes revealed increased CD206 expression both in hPL and in FBS, indicating an interaction between macrophages and chondrocytes. While markers in FBS-cultured macrophages were confirmed in hPL-cultured cells, the interpretation of marker modulation in immunomodulatory assays with hPL-based cultures should be carried out cautiously due to the observed differences in the basal marker levels for CD206 and CD163. This research underscores the utility of hPL as a GMP-compliant alternative to FBS for macrophage-based co-cultures and highlights the importance of understanding marker expressions in different culture conditions.

Decade-long insights: tracking asbestos-related health impacts among formerly exposed workers in Palermo, Italy.

Background: Asbestos is a foremost occupational carcinogen globally. Despite the prohibition under Law 257/1992, Italy persists as one of the European nations most burdened by asbestos-related diseases (ARDs). This research assessed ARD cases in asbestos-exposed workers from the Province of Palermo, Italy, spanning 2010-2021. Methods: Data acquisition utilized the epidemiological dataset from the 'Service of Prevention and Safety on Work Environment' under the Prevention Department of Palermo's Local Health Authority (LHA). Results: Between 2010 and 2021, we identified 245 ARD instances, comprising 163 Asbestosis/Pleural plaques, 41 Lung Cancers, 38 Mesotheliomas, and 3 unspecified cases. Multivariate analysis indicated a notable decline in temporal exposure for mesothelioma (HR=0.933; 95% CI=0.902-0.965) and lung cancer (HR=0.93; 95% CI=0.90-0.978) relative to pleural plaques/asbestosis. Tobacco use displayed a pronounced correlation with lung cancer (smoker HR=64.520 95% CI=13,075-318.390; former smoker HR=20.917 95% CI=4,913-89.048). A significant link was observed between mesothelioma and pleural plaques/asbestosis in those employed in shipbuilding and repair (HR=0.371 95% CI=0.155-0.892). Conclusions: ARDs persist in clinical observations, even following the 1992 cessation of asbestos-related activities, emphasizing an enduring public health challenge. Enhancing prevention strategies is paramount, focusing on amplifying anamnestic and occupational data collection, thereby facilitating superior early diagnosis strategies for these maladies in the occupationally exposed cohort.

Direct anterior approach with conventional instruments versus robotic posterolateral approach in elective total hip replacement for primary osteoarthritis: a case-control study.

BACKGROUND: The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA) versus a pair-matched cohort of patients who underwent robotic-assisted THA with posterolateral approach. MATERIALS AND METHODS: Data from consecutive patients who underwent elective hip replacement from 2021 to 2023 for primary OA were retrospectively retrieved and divided into two groups: the DAA group, who underwent THA with the DAA approach using conventional instruments, and the robotic posterolateral (R-PL group), who underwent robot arm-assisted THA with the posterolateral approach. Comparative assessed outcomes were: operative time, radiographical implant positioning, intake of rescue analgesics, blood loss, transfusion rate, leg length discrepancy and functional outcomes (Harris hip score and forgotten joint score). RESULTS: A total of 100 pair-matched patients were retrieved with a mean age of 66.7 ± 10.7 (range: 32-85) years and a mean follow-up of 12.8 ± 3.6 (range: 7-24) months. No differences in patients' characteristics were detected. Patients in the R-PL group required less rescue tramadol (p > 0.001), ketorolac (p = 0.028) and acetaminophen (p < 0.001). There was no significant difference in the operative time between (MD = 5.0 min; p = 0.071). Patients in the DAA group had significantly lower Hb levels at day 1 (p = 0.002) without significant differences in transfusion rate (p = 0.283). Patients in the R-PL group had shorter length of stay (LOS) with a mean difference of 1.8 days [p < 0.001; 95% confidence interval (CI) 1.4-2.3]. No difference in clinical outcomes was found [leg length discrepancy (LLD), p = 0.572; HHS, p = 0.558; forgotten joint score (FJS), p = 0.629]. No radiographical differences were measured in cup inclination (MD = 2.0°, p = 0.069), malpositioning [odd ratio (OR) = 0.2; p = 0.141], stem alignment (OR = 0.3; p = 0.485) and stem sizing (OR = 1.5; p = 1.000). There was no difference in complication rate except for lateral femoral cutaneous nerve damage, which was higher in DAA group (p < 0.001). CONCLUSIONS: R-PL and DAA THA had comparable short-term clinical and radiological outcomes along with similar complication rates. The R-PL group showed significantly lower Hb drop, rescue analgesic consumption and shorter LOS. This is a preliminary study and no strong recommendation can be provided. Further prospective randomized trials are requested to further investigate the cost-effectiveness of robotic surgery in THA. LEVEL OF EVIDENCE: Level IV, case-control study.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Impact of Actively Offering Influenza Vaccination to Frail People during Hospitalisation: A Pilot Study in Italy.

Despite the worldwide recommendations for influenza immunisation, vaccination coverage for patients exposed to the highest risk of severe complications is still far from the optimal target. The need to take advantage of alternative methods to provide vaccination is essential. This study presents a hospital-based strategy which offers influenza vaccination to inpatients at discharge. This study was conducted during the 2022-2023 influenza season at the University Hospital of Palermo. A questionnaire was administered to identify the determinants for the acceptance of influenza vaccination in the frail population. Overall, 248 hospitalised patients were enrolled, of which 56.1% were female and 52.0% were over 65 years of age. The proportion of patients vaccinated against influenza during hospitalisation was 62.5%, an increase of 16% in influenza vaccination uptake among frail people in comparison with the previous influenza season (46.8% vaccinated during the 2021-22 influenza season). Factors significantly associated with vaccination acceptance were the following: to have received influenza vaccine advice from hospital healthcare workers (OR = 3.57, p = 0.001), to have been previously vaccinated for influenza (OR = 3.16 p = 0.005), and to have had a low level of education (OR = 3.56, p = 0.014). This study showed that offering influenza vaccination to hospitalised patients could be an effective strategy to increase vaccination coverage in the most vulnerable population, and these findings could be useful for planning and improving future influenza vaccination campaigns.

Previous anterior cruciate ligament reconstruction influences the complication rate of total knee arthroplasty: a systematic review and meta-analysis.

Purpose: The results of total knee arthroplasty (TKA) following anterior cruciate ligament (ACL) reconstruction are still under-investigated. The purpose of this research is to investigate the differences between TKA after ACL reconstruction and TKA for primary osteoarthritis through a review and meta-analysis of the literature. Methods: Case-control and cohort studies reporting outcomes of TKA following ACL reconstruction were considered eligible for inclusion. The primary endpoint was to systematically review and meta-analyze the reported complications of TKA following ACL reconstruction. The outcomes have been compared with a group of patients who underwent TKA for primary knee osteoarthritis (OA) with any previous ACL surgery. Secondary endpoints were to assess and compare technical difficulties and results including the operative time, the use of revision components, the request for intraoperative release or additional procedures, the revision rate, and the clinical outcomes. Results: Seven studies were included involving 1645 participants, 619 of whom underwent TKA in previous ACL reconstruction and 1026 TKA for primary OA with no previous ACL reconstruction. Meta-analysis showed that TKA in previous ACL reconstruction had a significantly higher complication rate (OR = 2.15, P < 0.001), longer operative times (mean differences (MD): 11.19 min; P < 0.001) and increased use of revision components (OR = 2.16; P < 0.001) when compared to the control group without differences of infection, and revision rate. Conclusions: TKA in a previous ACL reconstruction has a significantly higher complication rate, longer operative times, and a higher need for revision components and intraoperative soft tissue releases in comparison to TKA for primary OA without previous ACL reconstruction.