The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients.

BACKGROUND: Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. AIMS: In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. METHODS: A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. RESULTS: A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). CONCLUSION: Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

Smart sensor implant technology in total knee arthroplasty.

Innovations in computer technology and implant design have paved the way for the development of smart instruments and intelligent implants in trauma and orthopaedics to improve patient-related functional outcomes. Sensor technology uses embedded devices that detect physical, chemical and biological signals and provide a way for these signals to be measured and recorded. Sensor technology applications have been introduced in various fields of medicine in the diagnosis, treatment and monitoring of diseases. Intelligent 'Smart' implants are devices that can provide diagnostic capabilities along with therapeutic benefits. In trauma and orthopaedics, applications of sensors is increasing because of the advances in microchip technologies for implant devices and research designs. It offers real-time monitoring from the signals transmitted by the embedded sensors and thus provides early management solutions. Smart orthopaedic implants have applications in total knee arthroplasty, hip arthroplasty, spine surgery, fracture healing, early detection of infection and implant loosening. Here we have explored the role of Smart sensor implant technology in total knee arthroplasty. Smart sensor assisted can be used intraoperatively to provide objective assessment of ligament and soft tissue balancing whilst maintaining the sagittal and coronal alignment to achieve desired kinematic targets following total knee arthroplasty. It can also provide post-implantation data to monitor implant performance in natural conditions and patient's clinical recovery during rehabilitation. The use of Smart Sensor implant technology in total knee arthroplasty appears to provide superior patient satisfaction rates and improved functional outcomes.

Using Fracture Patterns and Planned Operative Modality to Identify Fractured Neck of Femur Patients at High Risk of Blood Transfusion.

Background Fractured neck of femurs is common, serious injuries usually requiring operative management. Red blood cell transfusions are often required to treat perioperative anaemia, but these are not without adverse effects. Aims and objectives The aim of this study is to identify subgroups of fractured neck of femur patients more likely to require red blood cell transfusions. We try to identify targeted strategies to reduce blood transfusion-associated adverse effects and thus improve outcomes. Design and methods A retrospective cohort study of 324 patients. Patients were divided into cohorts based on radiological fracture patterns and operations performed. Data were collected from patient records, picture archiving and communication systems, the local transfusion laboratory, and the national hip fracture database. The primary outcome was blood transfusion rates in different fracture patterns in fractured necks of femur patients. The secondary outcome was blood transfusion rates in different operation types for fractured neck of femur patients. Chi-squared tests for independence were performed. Results 14.9%, 34.7% and 33.3% of patients with intracapsular, intertrochanteric and subtrochanteric fractures, respectively, received blood transfusions. There was a significant relationship between fracture pattern and blood transfusion (X 2 (2, N = 324) = 17.1687, p = 0.000187). 47% of patients receiving long intramedullary nails, 45% of short intramedullary nails, 27% of open reduction internal fixations, 18% of hemiarthroplasties and 9% of total hip arthroplasties resulted in blood transfusions. There was a significant relationship between operative modality and blood transfusion (X 2 (4, N = 302) = 22.0184, p = 0.000199). Conclusion In patients who have sustained a fractured neck of the femur, the fracture pattern and operative modality are both independently associated with the rates of red blood cell transfusion. In these identified groups, we propose that increased vigilance and awareness regarding transfusion avoiding strategies are utilised with the goal of improving patient outcomes.

Blood transfusions and hip fracture mortality - A retrospective cohort study.

BACKGROUND: Hip fractures are associated with serious morbidity and mortality. Low haemoglobin at presentation has been shown to be associated with increased mortality in hip fracture patients. This comorbid patient group commonly receives packed red cell blood transfusions during their hospital admission, the impact of which is less clear. AIMS AND OBJECTIVES: We aim to assess the rate, appropriateness and impact of blood transfusions on one-year mortality in hip fracture patients. We also aim to assess the impact of patients taking anticoagulant medications at presentation on the rates of blood transfusions in this patient group. METHODS: A retrospective cohort study of 324 consecutive hip fracture patients. Data was collected from the national hip fracture database, electronic patient records and PACS. RESULTS: 75 patients received a blood transfusion. Receiving a blood transfusion increased absolute risk of one-year mortality by 2.466 (p < 0.05). Adjusted for age, sex, comorbidities, residence prior to admission and time from presentation to surgery increased the risk of one-year mortality was 2.790 (p < 0.05).28% of patients who went on to receive a transfusion had a haemoglobin of less than 100 g/L at presentation. 94.6% of transfused patients had a pre-transfusion haemoglobin of less than 90 g/L. There was no increased risk of requiring a blood transfusion if anticoagulant medication was being taken at presentation. CONCLUSION: Receiving a blood transfusion during an admission for hip fracture carried an increased risk of one-year mortality of almost two and a half times. With appropriate preoperative optimisation, taking an anticoagulant medication at presentation did not increase the risk of requiring a transfusion. Most blood transfusions were administered appropriately using thresholds. Just over a quarter of patients who received a transfusion had an admission haemoglobin of less than 100 g/L, showing it as a poor predictor of blood transfusion requirement during admission.