Strategies to improve end-of-life decision-making and palliative care following hip fracture in frail older adults: a scoping review.

BACKGROUND: Although surgery is the gold standard following a hip fracture, the potential for rehabilitation and survival rates are low in frail older patients. Some patients may derive more benefit from palliative care. The objectives of this review were to identify the available strategies to improve end-of-life decision-making and palliative care for frail patients with hip fractures and to synthetise their level of support. METHODS: We conducted a scoping review of the scientific and grey literature, searching seven databases and websites of associations. We included all study designs, expert opinion articles and clinical practice guidelines (CPGs). Data were synthetised according to the Approach to Patient with Limited Life Expectancy and Hip Fracture framework. The number of research items and their level of evidence were tabulated for each of the recommended strategies. RESULTS: Of the 10 591 items identified, 34 were eligible. The majority of included articles were original research studies (n = 15). Half of the articles and CPGs focused on intervention categories (55%) such as goals of care discussion and comfort care, followed by factors to consider in the end-of-life decision-making process (25%) and prognosis assessments (20%), mainly through the estimation of life expectancy. The level of evidence for these strategies remains low, given the limited number of prospective studies supporting them. CONCLUSIONS: This scoping review highlighted that end-of-life care in frail older patients with a hip fracture remains understudied. The strategies identified could be prioritised for future research to improve the well-being of the target population while promoting sustainable resource management.

Knee braces and foot orthoses multimodal 3-month treatment of medial knee osteoarthritis in a randomised crossover trial.

PURPOSE: Immediate biomechanical and functional benefits of knee braces and lateral wedge foot orthoses (FO) are often reported on patients with medial knee osteoarthritis. However, the effectiveness of their combined use in a longer-term orthotic treatment remains unclear. The aim was to evaluate pain, function, comfort and knee adduction moment (KAM) during the stance phase of gait with three modalities of orthotic treatment. METHODS: Twenty-two patients with knee osteoarthritis were analysed in a randomised crossover trial including a knee brace with valgus and external rotation functions (VER), FO and their combined use (VER + FO). Western Ontario and McMaster Universities scale (WOMAC) and Knee injury and Osteoarthritis Outcome Scores and KAM during gait were obtained before and after each orthotic treatment of 3 months. Repeated measures analyses of variance contrasted the factors orthosis (VER, FO, VER + FO), treatment (pre and post) and wear (without and with) on pain, function, comfort and KAM. RESULTS: An interaction between orthosis and treatment on the WOMAC pain (effect size [ES] = 0.17) and a main effect on the pain visual analogue score (ES = 0.24) indicated that VER and VER + FO were more alleviating than FO. The three modalities of orthotic treatment significantly improved functional scores (ES > 0.2) and reduced discomfort (ES = 0.25). A significant multivariate interaction between orthosis and wear (ES = 0.73) showed that the KAM reduction while wearing the orthoses was more pronounced with the VER and VER + FO than the FO. CONCLUSION: The VER-brace obtained more effectiveness than FO on pain and KAM after 3 months for medial knee osteoarthritis and the combined treatment did not substantially improve biomechanical and functional outcomes. LEVEL OF EVIDENCE: Therapeutic study level I randomised crossover trial.

Sleep Apnea is Not an Obstacle for Outpatient Hip and Knee Arthroplasty.

BACKGROUND: Up to 25% of patients requiring hip or knee arthroplasty have sleep apnea (SA), and these patients have historically been excluded from outpatient programs. The objectives of this study were to evaluate same-day discharge failure as well as 30-day complications, readmissions, and unexpected visits. METHODS: A retrospective case-control study comparing patients who have and do not have SA matched for age, sex and arthroplasty type (total hip arthroplasty, total knee arthroplasty, unicompartimental knee arthroplasty) who underwent primary outpatient surgery between February 2019 and December 2022 in 2 academic hospitals was conducted. Cases with mild SA, moderate SA with a body mass index (BMI) <35, and SA of all severity treated by continuous positive airway pressure machines were eligible. There were 156 patients included (78 cases). Complications were assessed according to the Clavien-Dindo Classification and the Comprehensive Complication Index. Continuous variables were evaluated by Student's T or Mann-Whitney tests, while categorical data were analyzed by Chi-square or Fisher tests. Univariate analyses were performed to determine discharge failure risk factors. RESULTS: There were 6 cases (7.7%) and 5 controls (6.4%) who failed to be discharged on surgery day (P = .754), with postoperative hypoxemia (6, [3.8%]) and apnea periods (3, [1.9%]) being the most common causes. Higher BMI (odds ratio = 1.19, P = .013) and general anesthesia (odds ratio = 11.97, P = .004) were found to be risk factors for discharge failure. No difference was observed on 30-day readmissions (P = .497), unexpected visits (P = 1.000), and complications on the Clavien-Dindo Classification (P > .269) and Comprehensive Complication Index (P > .334) scales. CONCLUSIONS: Selected patients who have SA can safely undergo outpatient hip or knee arthroplasty. Higher BMI and general anesthesia increased the odds of same-day discharge failure. LEVEL OF EVIDENCE: Level III, Case-control Study.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study.

BACKGROUND: Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury. METHODS: We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination). RESULTS: Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes. CONCLUSION: We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study.

OBJECTIVE: Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN: A consensus study using the nominal group technique. SETTING: Four trauma systems in Canada. SUBJECTS: Participants included expert clinicians and decision makers, and people with lived experience. METHODS: Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS: A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION: This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey.

PURPOSE: To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS: We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS: Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS: Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

RéSUMé: OBJECTIF: Évaluer comment les cliniciens canadiens impliqués dans les soins aux patients traumatisés et prescrivant des opioïdes perçoivent l'utilisation et l'efficacité des stratégies visant à prévenir le traitement prolongé par opioïde après un traumatisme. Les obstacles et facilitateurs de la mise en œuvre de ces stratégies ont aussi été analysés. MéTHODES: Nous avons réalisé une enquête transversale via le Web. Les participants potentiels ont été identifiés par les gestionnaires et directeurs de programmes de traumatologie des départements ciblés dans trois provinces canadiennes. Nous avons conçu notre questionnaire en utilisant la méthodologie de recherche usuelle des enquêtes de santé. Le questionnaire a été administré entre avril 2021 et novembre 2021. RéSULTATS: Notre taux de réponse a été de 47 % (350/744) et 52 % (181/350) des participants ont complété l'enquête dans sa totalité. La majorité des personnes interrogées (71 %, 129/181) travaillait dans des hôpitaux universitaires. L'analgésie multimodale (93 %, 240/257), les anti-inflammatoires non stéroïdiens (77 %, 198/257) et la stimulation physique (75 %, 193/257) étaient les stratégies perçues comme étant le plus fréquemment utilisées. Plusieurs stratégies préventives étaient perçues comme étant très efficaces par plus de 80 % des répondants. Parmi celles-ci, certaines étaient signalées comme n'étant pas utilisées très souvent, mais perçues comme étant les plus efficaces, notamment les lignes directrices et protocoles évaluant les facteurs de risque d'utilisation abusive des opioïdes, le suivi de la santé physique par un professionnel, la formation des cliniciens, l'éducation des patients et les systèmes de suivi des prescriptions. La pénurie de personnels, les contraintes de temps et les pratiques de l'établissement ont été identifiées comme étant les principaux obstacles à la mise en place des stratégies préventives classées parmi les premières. CONCLUSIONS: Plusieurs stratégies de prévention du traitement par opioïdes à long terme après un traumatisme sont perçues comme efficaces par ceux qui les prescrivent à cette population de patients. Certaines de ces stratégies apparaissent comme couramment utilisées dans la pratique quotidienne et d'autres moins souvent. La recherche future devrait se concentrer sur la détermination des stratégies préventives auxquelles il faudrait accorder la plus grande priorité de mise en œuvre avant d'évaluer leur efficacité.

The impact of Canadian-produced research on the global orthopedic literature: a bibliometric analysis.

BACKGROUND: Little is known about the quality and impact of Canadian-produced research relative to that of other developed nations. The purpose of this study was to determine the contribution of Canadian authors to the orthopedic literature globally and nationally as well as Canada's research productivity in orthopedics. We hypothesized that Canada ranks among the most impactful countries in terms of orthopedic research productivity. METHODS: We performed a bibliometric analysis to identify articles published between 2001 and 2020 in the category of orthopedics. We identified Canada's global rank in terms of overall productivity and assessed the contributions of individual Canadian authors. We also examined the quality of publications as determined by category normalized citation impact (CNCI) and publication in the top quartile of journals (%Q1) in terms of impact factor. In addition, we calculated the percentage of Canadian publications that were in orthopedics. RESULTS: We identified 10 821 orthopedic publications from 2001 to 2020. Canada placed sixth globally in terms of productivity in orthopedic research. The annual productivity of Canadian orthopedic researchers increased over the study period by a factor of 3.2. In terms of research quality, with a %Q1 of 36.5% and a CNCI of 1.22, Canada outperformed Asian countries and the United States; the latter country had a %Q1 of 35.3% and a CNCI of 1.14 over the study period. CONCLUSION: The body of Canadian orthopedic literature has grown consistently over the past 20 years. Despite the overall leadership of the United States and other developed nations such as China and Japan, Canada ranks among the most influential countries in terms of the quality and quantity of orthopedic research.

Should We Use Bipolar Hemiarthroplasty in Patients ≥70 Years Old With a Femoral Neck Fracture? A Review of Literature and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Bipolar (BHA) and unipolar hemiarthroplasties (UHA) are interchangeably used in elderly patients with a displaced femoral neck fracture. We ask if there is a difference between BHA and UHA with regards to hip function, in elderly patients. METHODS: Systematic review and meta-analysis was conducted of randomized controlled trials comparing BHA to UHA. The primary outcome was postoperative hip function scores. Secondary outcomes were overall health-related quality of life patient-reported outcomes, acetabular erosion, and postoperative complications. Data sources, last searched on June 1, 2020, were MEDLINE, EMBASE, Cochrane Library, and Web of Science. RESULTS: Fourteen randomized controlled trials were eligible for meta-analysis. There was no difference in hip function scores between BHA and UHA (standardized mean difference 0.32, 95% confidence interval [CI] -0.06 to 0.71, n = 1084, I2 = 87%). Patients with BHA with more than 2-year follow-up had better hip function scores (standardized mean difference 0.68, 95% CI 0.18-1.18, n = 700, I2 = 87%). There was no difference in European Quality of life- five dimensions scores with BHA (mean difference 0.08, 95% CI -0.01 to 0.17, n = 967, I2 = 82%). The use of BHA decreased the risk of acetabular erosion (relative risk 0.38, 95% CI 0.17-0.83, n = 1239, I2 = 0%). There was no difference for revision, mortality, infection, and dislocation (I2 = 0%). CONCLUSION: There seems to be no difference between BHA and UHA with regards to hip function at 2 years. BHA might decrease the risk of acetabular erosion. There is a need for a large randomized controlled trial with a follow-up >2 years and better measurement tools to assess clinical benefits. LEVEL OF EVIDENCE: II.

Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty.

BACKGROUND: Clinical trials and meta-analyses have suggested that aspirin may be effective for the prevention of venous thromboembolism (proximal deep-vein thrombosis or pulmonary embolism) after total hip or total knee arthroplasty, but comparisons with direct oral anticoagulants are lacking for prophylaxis beyond hospital discharge. METHODS: We performed a multicenter, double-blind, randomized, controlled trial involving patients who were undergoing total hip or knee arthroplasty. All the patients received once-daily oral rivaroxaban (10 mg) until postoperative day 5 and then were randomly assigned to continue rivaroxaban or switch to aspirin (81 mg daily) for an additional 9 days after total knee arthroplasty or for 30 days after total hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (the primary effectiveness outcome) and bleeding complications, including major or clinically relevant nonmajor bleeding (the primary safety outcome). RESULTS: A total of 3424 patients (1804 undergoing total hip arthroplasty and 1620 undergoing total knee arthroplasty) were enrolled in the trial. Venous thromboembolism occurred in 11 of 1707 patients (0.64%) in the aspirin group and in 12 of 1717 patients (0.70%) in the rivaroxaban group (difference, 0.06 percentage points; 95% confidence interval [CI], -0.55 to 0.66; P<0.001 for noninferiority and P=0.84 for superiority). Major bleeding complications occurred in 8 patients (0.47%) in the aspirin group and in 5 (0.29%) in the rivaroxaban group (difference, 0.18 percentage points; 95% CI, -0.65 to 0.29; P=0.42). Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group (difference, 0.30 percentage points; 95% CI, -1.07 to 0.47; P=0.43). CONCLUSIONS: Among patients who received 5 days of rivaroxaban prophylaxis after total hip or total knee arthroplasty, extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT01720108 .).

Low-value injury care in the adult orthopaedic trauma population: A systematic review.

OBJECTIVES: Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS: We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS: Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION: In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

The dimensions of the hip capsule can be measured using magnetic resonance imaging and may have a role in arthroscopic planning.

PURPOSE: The purpose of this study was to systematically evaluate the dimensions and thickness of the hip joint capsule. Secondarily, the study assessed whether there were any described correlations between capsule thickness and stability of the hip joint. METHODS: Four databases (PubMed, Ovid [MEDLINE], Cochrane Database, and EMBASE) were searched from database inception to May 2018, and two reviewers independently and in duplicate screened the resulting literature. Methodological quality of all included papers was assessed using the Methodological index for non-randomized studies (MINORS) criteria. Mean differences were combined in a meta-analysis using a random effects model when possible. RESULTS: A total of 14 studies (1 level I, 1 level II, 4 level III, 5 level IV) were identified including 796 patients (1013 hips) with a mean age of 39.5 years (range 2-95). Of the included patients, 55.2% were female and they were followed up for a mean of 7.6 months (range 1-12.5 months). The thickness of the capsule was measured in cadaveric specimens, ultrasound, and magnetic resonance imaging (MRI), with MRI measurements reported most consistently and with the least variation. Mean thickness of the anterior capsule in patients without hip disease on MRI ranged from 4.4 and 4.7 mm. Mean thickness of the anterior capsule in patients with FAI ranged between 4.9 and 5.0 mm. Males had significantly thicker capsules than females (mean difference = 1.92 mm, 0.35-3.49, P = 0.02). Clinical laxity of the hip joint, as well as female gender was correlated with thinner anterior joint capsules. CONCLUSION: The thickness of the anterior hip capsule can be measured consistently using MRI. A thinner anterior capsule may be associated with clinical laxity of the hip joint. The relevance of capsular thickness on postoperative instability following hip arthroscopy is poorly understood and warrants further investigation. The thickness of the anterior hip capsule, as measured on MRI, has the potential to be used as part of the clinical decision-making in capsular management strategies. LEVEL OF EVIDENCE: IV.

Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis.

PURPOSE: Intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) have individually demonstrated efficacy for knee osteoarthritis (OA); however, both treatments are limited by the trajectory of symptom relief. The combination of CS and HA in the management of knee OA may provide improved symptomatic relief for patients who are candidates for intra-articular therapies. METHODS: Electronic databases Medline, EMBASE and Cochrane Library were used to identify relevant publications. Randomized controlled trials (RCT) that evaluated intra-articular injections of combined CS and HA in comparison to HA alone were included. Outcomes eligible for meta-analysis were WOMAC pain, WOMAC total, OMERACT-OARSI responder rate, and treatment-related adverse events. Standardized mean differences (SMD) were calculated for continuous outcomes using an inverse variance method and a random-effects model. Odds ratios (OR) were calculated for dichotomous outcomes using the Mantel-Haenszel method and a random-effects model. Heterogeneity was assessed using the I2 statistic. RESULTS: Eight trials (n = 751 patients) were included. Reduction in WOMAC pain scores at 2-4 weeks favoured the combined CS and HA group compared to HA alone [SMD 0.60, 95% CI (0.23, 0.97); p = 0.002, I2 = 75%]. Longer term improvements at 24-26 and 52 weeks WOMAC pain scores also favoured the combined CS and HA group {[SMD 0.25, 95% CI (0.09, 0.41); p = 0.002, I2 = 0%] and [SMD 0.39, 95% CI (0.01, 0.77); p = 0.05, I2 = 0%]} compared to HA alone, respectively. There were no significant differences in WOMAC total scores, OMERACT-OARSI responder rate, or treatment-related adverse events. CONCLUSION: Combined intra-articular injections of CS and HA led to reductions in pain at 2-4, 24-26 and 52 weeks compared to HA injections alone. LEVEL OF EVIDENCE: Level II-meta-analysis.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy.

PURPOSE: Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted. RESULTS: Twenty-four studies (n = 3405) were included, with the majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7 years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1 months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68 min with complication rates of 10% and 6.6%, respectively. CONCLUSIONS: Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction. LEVEL OF EVIDENCE: Level IV, systematic review of level I-IV studies.

Analysis of contributing factors influencing thromboembolic events after total knee arthroplasty.

BACKGROUND: Venous thromboembolic events (VTE) are a known and well-described complication following total knee arthroplasty (TKA). We sought to validate the American College of Chest Physicians thromboprophylaxis recommendations after elective TKA, paying special attention to our dose adjustments for weight, and their impact on VTE in our population. METHODS: We retrospectively investigated risk factors in patients undergoing TKA, focusing mainly on symptomatic VTE occurrence rates from deep vein thrombosis (DVT) or pulmonary embolism (PE). The anticoagulation protocol consisted of starting low molecular-weight heparin (LMWH) therapy, with dalteparin administered 12 h after surgery in patients who received general anesthesia or 24 h later in patients who received single-dose regional anesthesia. RESULTS: Data from 346 patients (mean age 66.8 [range 24-91] yr) who underwent primary or revision TKA depicted an overall symptomatic VTE rate of 15%. The proximal DVT rate was 1.7%, and the nonfatal PE rate was 0.9%. The mean time to VTE diagnosis was 5.6 days. The first dalteparin dose was administered 19.5 (range 10-48) h after surgery in patients without VTE and 22.6 (range 11.5-52) h after surgery in patients with VTE (p = 0.003). With a first dose of dalteparin administered 12 h postoperatively, patients presented significantly lower DVT and PE rates than if it was administered 24 h postoperatively (8.5% v. 16.3%, p = 0.048). CONCLUSION: Delayed administration of LMWH has deleteriously impacted the VTE rate after TKA at our institution. Prompt initiation of LMWH (≤ 12 h after surgery) is appropriate, without increasing the risk of major bleeding.

CONTEXTE: Les événements thromboemboliques veineux (ETV) sont une complication connue et bien décrite de la chirurgie pour prothèse totale du genou (PTG). Nous avons voulu valider les recommandations de l'American College of Chest Physicians en matière de thromboprophylaxie après la PTG non urgente en portant une attention particulière à l'ajustement des doses selon le poids et à leur impact sur les ETV dans notre population. MÉTHODES: Nous avons analysé de manière rétrospective les facteurs de risque chez des patients soumis à une PTG en nous attardant principalement aux taux d'ETV symptomatiques sous forme de thrombose veineuse profonde (TVP) ou d'embolie pulmonaire (EP). Le protocole d'anticoagulothérapie prévoyait l'administration d'une héparine de bas poids moléculaire (HBPM), la daltéparine, 12 h après la chirurgie chez les patients ayant reçu une anesthésie générale, ou 24 h après chez les patients ayant reçu une anesthésie locorégionale à dose unique. RÉSULTATS: Les données provenant de 346 patients (âgés en moyenne de 66,8 and [éventail 24-91 and]) ayant subi une PTG primaire ou une révision de PTG ont révélé un taux d'ETV symptomatique global de 15 %. Le taux de TVP proximal a été de 1,7 % et le taux d'EP non fatale a été de 0,9 %. Le temps moyen avant le diagnostic d'ETV a été 5,6 jours. La première dose de daltéparine avait été administrée 19,5 h (éventail 10-48 h) après la chirurgie chez les patients n'ayant pas présenté d'ETV et 22,6 h (éventail 11,5-52 h) après la chirurgie chez les patients ayant manifesté un ETV (p = 0,003). Avec une première dose de daltéparine administrée 12 h après l'intervention, les patients ont présenté des taux de TVP et d'EP significativement moindres que si elle leur avait été administrée 24 h après l'intervention (8,5 % c. 16,3 %, p = 0,048). CONCLUSION: L'administration retardée de l'HBPM a produit des effets défavorables pour ce qui est des taux d'ETV après la PTG dans notre établissement. L'instauration rapide de l'HBPM (≤ 12 h après la chirurgie) est appropriée et n'accroît pas le risque d'hémorragie majeure.

Patient Satisfaction with In-Home Telerehabilitation After Total Knee Arthroplasty: Results from a Randomized Controlled Trial.

Background and Introduction: Telerehabilitation after total knee arthroplasty (TKA) is supported by strong evidence on the effectiveness of such intervention and from a cost-benefit point of view. Satisfaction of patients toward in-home telerehabilitation after TKA has not yet been examined thoroughly in large-scale clinical trials. This study aims to compare satisfaction level of patients following in-home telerehabilitation (TELE) after TKA to one of the patients following a usual face-to-face home visit (STD) rehabilitation. Secondarily, to determine if any clinical or personal variables were associated to the level of satisfaction. MATERIALS AND METHODS: This study was embedded in a multicenter randomized controlled trial with 205 patients randomized into two groups. Rehabilitation intervention was the same for both groups; only approach for service delivery differed (telerehabilitation or home visits). Participants were assessed at baseline (before TKA), at hospital discharge, and at 2 and 4 months postdischarge (E4) using functional outcomes. Patient satisfaction was measured using the validated Health Care Satisfaction Questionnaire (HCSQ) at E4. RESULTS: Characteristics of all participants were similar at baseline. Satisfaction level of both groups did not differ and was very high (over 85%). It was neither correlated to personal characteristics nor to improvements of functional level from preoperative to E4. Satisfaction was rather found associated to walking and stair-climbing performances. CONCLUSIONS: These results, in conjunction with evidences of clinical effectiveness and cost benefits demonstrated in the same sample of patients, strongly support the use of telerehabilitation to improve access to rehabilitation services and efficiency of service delivery after TKA.

Gross Instability After Hip Arthroscopy: An Analysis of Case Reports Evaluating Surgical and Patient Factors.

PURPOSE: Gross hip instability is a rare complication after hip arthroscopy, and there is limited literature surrounding this topic. This systematic review investigates cases of gross hip instability after arthroscopy and discusses the risk factors associated with this complication. METHODS: A systematic search was performed in duplicate for studies investigating gross hip instability after hip arthroscopy up to October 2015. Study parameters including sample size, mechanism and type of dislocation, surgical procedure details, patient characteristics, postoperative rehabilitation protocol, and level of evidence were analyzed. RESULTS: The systematic review identified 9 case reports investigating gross hip instability after hip arthroscopy (10 patients). Anterior dislocation occurred in 66.7% of patients, and most injuries occurred with a low-energy mechanism. Common surgical factors cited included unrepaired capsulotomy (77.8%) and iliopsoas release (33.3%), whereas patient factors included female gender (77.8%), acetabular dysplasia (22.2%), and general ligamentous laxity (11.1%). Postoperative restrictions and protocols were variable and inconsistently reported, and their relation to post-arthroscopy instability was difficult to ascertain. CONCLUSIONS: This systematic review discussed various patient, surgical, and postoperative risk factors of gross hip instability after arthroscopy. Patient characteristics such as female gender, hip dysplasia, and ligamentous laxity may be risk factors for post-arthroscopy dislocation. Similarly, surgical risk factors for iatrogenic hip instability may include unrepaired capsulotomies and iliopsoas debridement, although the role of capsular closure in iatrogenic instability is not clear. The influences of postoperative restrictions and protocols on dislocation are also unclear in the current literature. Surgeons should be cognizant of these risk factors when performing hip arthroscopy and be mindful that these factors appear to occur in combination. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Evaluating healthcare resource utilization and outcomes for surgical hip dislocation and hip arthroscopy for femoroacetabular impingement.

PURPOSE: Surgical hip dislocation (SHD) and hip arthroscopy are surgical methods used to correct deformity associated with femoroacetabular impingement (FAI). Though both of these approaches appear to benefit patients, no studies exist comparing healthcare resource utilization of the two surgical approaches. This systematic review examines the literature and the records of two surgeons to evaluate the resource utilization associated with treating symptomatic FAI via these two methods. METHODS: EMBASE, MEDLINE and PubMed were searched for relevant articles. The articles were systematically screened, and data was abstracted in duplicate. To further supplement resource utilization data, a retrospective chart review of two surgeon's patient data (one using SHD and another using an arthroscopic approach) was completed. Experts in pharmacy, physiotherapy, radiology, anaesthesia, physiatry and the local hospital finance department were also consulted. RESULTS: There were 52 studies included with a total of 460 patients (535 hips) and 3886 patients (4147 hips) who underwent SHD and arthroscopic surgery for FAI, respectively. Regardless of approach, most patients treated for symptomatic FAI improved across various outcomes measures with low complication rates. Surgical time across all approaches was similar, averaging 118 ± 2 min. On a per patient basis, hip arthroscopy ($10,976) uses approximately 41 % of the resources of SHD ($24,379). CONCLUSION: There were no significant differences in outcomes for FAI treated with SHD or arthroscopy. However, with regard to healthcare resource utilization based on the OHIP healthcare system, hip arthroscopy uses substantially less resources than SHD within the first post-operative year. LEVEL OF EVIDENCE: Systematic Review of Level IV Studies, Level IV.

Conditions of Use, Reliability, and Quality of Audio/Video-Mediated Communications During In-Home Rehabilitation Teletreatment for Postknee Arthroplasty.

BACKGROUND: Audio/video-mediated communication between patients and clinicians using videoconferencing over telecommunication networks is a key component of providing teletreatments in rehabilitation. OBJECTIVE: The objectives of this study were to (1) document the conditions of use, performance, and reliability of videoconferencing-based communication in the context of in-home teletreatment (TELE) following total knee arthroplasty (TKA) and (2) assess from the perspective of the providers, the quality attributes of the technology used and its impact on clinical objectives. MATERIALS AND METHODS: Descriptive embedded study in a randomized controlled trial using a sample of 97 post-TKA patients, who received a total of 1,431 TELE sessions. Technical support use, service delivery reliability, performance, and use of network connection were assessed using self-report data from a costing grid and automated logs captured from videoconferencing systems. Physical therapists assessed the quality and impact of video-mediated communications after each TELE session on seven attributes. RESULTS: Installation of a new Internet connection was required in 75% of the participants and average technician's time to install test and uninstall technology (including travel time) was 308.4 min. The reliability of service delivery was 96.5% of planned sessions with 21% of TELE session requiring a reconnection during the session. Remote technical support was solicited in 43% of the sessions (interventions were less than 3-min duration). Perceived technological impacts on video-mediated communications were minimal with quality of the overall technical environment evaluated as good or acceptable in 96% of the sessions and clinical objectives reached almost completely or completely in 99% of the sessions. CONCLUSIONS: In-home rehabilitation teletreatments can be delivered reliably but requires access to technical support for the initial setup and maintenance. Optimization of the processes of reliably connecting patients to the Internet, getting the telerehabilitation platform in the patient's home, installing, configuring, and testing will be needed to generalize this approach of service delivery.

Cost analysis of in-home telerehabilitation for post-knee arthroplasty.

BACKGROUND: Rehabilitation provided through home visits is part of the continuum of care after discharge from hospital following total knee arthroplasty (TKA). As demands for rehabilitation at home are growing and becoming more difficult to meet, in-home telerehabilitation has been proposed as an alternate service delivery method. However, there is a need for robust data concerning both the effectiveness and the cost of dispensing in-home telerehabilitation. OBJECTIVE: The objective of this study was to document, analyze, and compare real costs of two service delivery methods: in-home telerehabilitation and conventional home visits. METHODS: The economic analysis was conducted as part of a multicenter randomized controlled trial (RCT) on telerehabilitation for TKA, and involved data from 197 patients, post-TKA. Twice a week for 8 weeks, participants received supervised physiotherapy via two delivery methods, depending on their study group allocation: in-home telerehabilitation (TELE) and home-visit rehabilitation (VISIT). Patients were recruited from eight hospitals in the province of Quebec, Canada. The TELE group intervention was delivered by videoconferencing over high-speed Internet. The VISIT group received the same intervention at home. Costs related to the delivery of the two services (TELE and VISIT) were calculated. Student's t tests were used to compare costs per treatment between the two groups. To take distance into account, the two treatment groups were compared within distance strata using two-way analyses of variance (ANOVAs). RESULTS: The mean cost of a single session was Can $93.08 for the VISIT group (SD $35.70) and $80.99 for the TELE group (SD $26.60). When comparing both groups, real total cost analysis showed a cost differential in favor of the TELE group (TELE minus VISIT: -$263, 95% CI -$382 to -$143). However, when the patient's home was located less than 30 km round-trip from the health care center, the difference in costs between TELE and VISIT treatments was not significant (P=.25, .26, and .11 for the <10, 10-19, and 20-29 km strata, respectively). The cost of TELE treatments was lower than VISIT treatments when the distance was 30 km or more (30-49 km: $81<$103, P=.002; ≥50 km: $90<$152, P<.001). CONCLUSIONS: To our knowledge, this is the first study of the actual costs of in-home telerehabilitation covering all subcosts of telerehabilitation and distance between the health care center and the patient's home. The cost for a single session of in-home telerehabilitation compared to conventional home-visit rehabilitation was lower or about the same, depending on the distance between the patient's home and health care center. Under the controlled conditions of an RCT, a favorable cost differential was observed when the patient was more than 30 km from the provider. Stakeholders and program planners can use these data to guide decisions regarding introducing telerehabilitation as a new service in their clinic. TRIAL REGISTRATION: International Standard Registered Clinical Study Number (ISRCTN): 66285945; http://www.isrctn.com/ISRCTN66285945 (Archived by WebCite at http://www.webcitation.org/6WlT2nuX4).