The Biomechanical Burden of Orthopaedic Procedures and Musculoskeletal Injuries Sustained by Orthopaedic Surgeons: A Systematic Review.

BACKGROUND: Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal (MSK) injuries and chronic pain due to repetitive large magnitude forces, altered posture from lead vests, and prolonged irregular body positions. We sought to synthesize available evidence regarding (1) the biomechanics of orthopaedic surgery and (2) MSK injuries sustained by orthopaedic surgeons with subsequent treatment and consequences. METHODS: To conduct this systematic review, we queried 4 databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or MSK injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on non-MSK injuries and injuries in patients or nonorthopaedic specialists. The literature search yielded 3,202 publications, 34 of which were included in the final analysis. RESULTS: Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of operating time slouched. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-six studies reported on MSK symptoms and injuries experienced by orthopaedic surgeons, with an overall prevalence from 44% to 97%. The most common body regions involved were lower back (15.2%-89.5%), hip/thigh (5.0%-86.6%), neck (2.4%-74%), hand/wrist (10.5%-54%), shoulder (7.1%-48.5%), elbow (3.1%-28.3%), knee/lower leg (7.9%-27.4%), and foot/ankle (7%-25.7%). Of surgeons with any reported MSK symptom or injury, 27% to 65.7% required nonoperative treatment, 3.2% to 34.3% surgery, and 4.5% to 31% time off work. Up to 59.3% of surgeons reported that their injuries would negatively influence their ability to perform surgical procedures in the future. CONCLUSIONS: The orthopaedic surgeon population experiences a high prevalence of MSK symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Determining a preoperative international normalised ratio threshold safe for hip fracture surgery.

INTRODUCTION: The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: <1.4; ⩾1.4 and <1.6; ⩾1.6 and <1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors. RESULTS: Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR < 1.4; 867 (2.4%) an INR ⩾1.4 and <1.6; 865 (2.4%) an INR ⩾ 1.6 and <1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality. CONCLUSIONS: We found that an INR of <1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients.