Assessment of deep vein thrombosis using routine pre- and postoperative duplex Doppler ultrasound in patients with pelvic trauma : a prospective study.

AIMS: The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. METHODS: All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. RESULTS: A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. CONCLUSION: The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283-289.

Laboratory-based versus qualitative assessment of α-defensin in periprosthetic hip and knee infections: a systematic review and meta-analysis.

INTRODUCTION: Two methods are currently available for the assay of α-defensin: the enzyme-linked immunosorbent assay (ELISA) and the lateral flow test. We aimed to assess the diagnostic accuracy of synovial fluid α-defensin and to compare the accuracy of the laboratory-based test and the qualitative assessment for the diagnosis of hip and knee prosthetic infection. MATERIALS AND METHODS: We searched (from inception to May 2018) MEDLINE, Scopus, EMBASE, Web of Science, and Cochrane for studies on α-defensin in the diagnosis of periprosthetic joint infection (PJI). Sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio were analyzed using the bivariate diagnostic random-effects model. The receiver-operating curve for each method was calculated. RESULTS: We included 13 articles in our meta-analysis, including 1170 patients who underwent total hip and knee arthroplasties revision; 368 (31%) had a joint infection according to MSIS and MSIS-modified criteria. Considering the false-positive result rate of 8% and false-negative result rate of 3%, pooled sensitivity and specificity were 0.90 (95% CI 0.83-0.94) and 0.95 (0.92-0.96), respectively. The area under the curve (AUC) was 0.94 (0.92-0.94). No statistical differences in terms of sensitivity and specificity were found between the laboratory-based and qualitative test. The pooled sensitivity and specificity of the two alpha-defensin assessment methods were: laboratory-based test 0.97 (95% CI 0.93-0.99) and 0.96 (95% CI 0.94-0.98), respectively; qualitative test 0.83 (95% CI 0.73-0.91) and 0.94 (95% CI 0.89-0.97), respectively. The diagnostic odds ratio of the α-defensin laboratory based was superior to that of the qualitative test (1126.085, 95% CI 352.172-3600.702 versus 100.9, 95% CI 30.1-338.41; p < 0.001). The AUC for immunoassay and qualitative tests was 0.97 (0.95-0.99) and 0.91 (0.88-0.99), respectively. CONCLUSION: Detection of α-defensin is an accurate test for diagnosis of hip and knee prosthetic infections. The diagnostic accuracy of the two alpha-defensin assessment methods is comparable. The lateral flow assay is a valid, rapid, and more available diagnostic tool, particularly to rule out PJI.

Improving performances of the knee replacement surgery process by applying DMAIC principles.

RATIONALE, AIMS, AND OBJECTIVES: The work is a part of a project about the application of the Lean Six Sigma to improve health care processes. A previously published work regarding the hip replacement surgery has shown promising results. Here, we propose an application of the DMAIC (Define, Measure, Analyse, Improve, and Control) cycle to improve quality and reduce costs related to the prosthetic knee replacement surgery by decreasing patients' length of hospital stay (LOS) METHODS: The DMAIC cycle has been adopted to decrease the patients' LOS. The University Hospital "Federico II" of Naples, one of the most important university hospitals in Southern Italy, participated in this study. Data on 148 patients who underwent prosthetic knee replacement between 2010 and 2013 were used. Process mapping, statistical measures, brainstorming activities, and comparative analysis were performed to identify factors influencing LOS and improvement strategies. RESULTS: The study allowed the identification of variables influencing the prolongation of the LOS and the implementation of corrective actions to improve the process of care. The adopted actions reduced the LOS by 42%, from a mean value of 14.2 to 8.3 days (standard deviation also decreased from 5.2 to 2.3 days). CONCLUSIONS: The DMAIC approach has proven to be a helpful strategy ensuring a significant decreasing of the LOS. Furthermore, through its implementation, a significant reduction of the average costs of hospital stay can be achieved. Such a versatile approach could be applied to improve a wide range of health care processes.

Lean Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery.

RATIONALE, AIMS AND OBJECTIVES: In 2012, health care spending in Italy reached €114.5 billion, accounting for 7.2% of the Gross Domestic Product (GDP) and 14.2% of total public spending. Therefore, reducing waste in health facilities could generate substantial cost savings. The objective of this study is to show that Lean Six Sigma represents an appropriate methodology for the development of a clinical pathway which allows to improve quality and to reduce costs in prosthetic hip replacement surgery. METHODS: The methodology used for the development of a new clinical pathway was Lean Six Sigma. Problem solving in Lean Six Sigma is the DMAIC (Define, Measure, Analyse, Improve, Control) roadmap, characterized by five operational phases which make possible to reach fixed goals through a rigorous process of defining, measuring, analysing, improving and controlling business problems. RESULTS: The following project indicated several variables influencing the inappropriate prolongation of the length of stay for inpatient treatment and corrective actions were performed to improve the effectiveness and efficiency of the process of care. The average length of stay was reduced from 18.9 to 10.6 days (-44%). CONCLUSION: This article shows there is no trade-off between quality and costs: Lean Six Sigma improves quality and, at the same time, reduces costs.