Control of Haemorrhage in Orthopaedic Trauma.

This paper aims to outline current practices and examine promising new advancements in the modern management of haemorrhage in orthopaedic trauma. Many prehospital and perioperative haemorrhage control strategies and techniques have been available to clinicians for multiple decades, yet our understanding and utilisation of these practices continues to be refined and optimised. There is a particular focus in this article on issues related to resuscitation and coagulation in trauma. We examine the complex mechanisms that lead to coagulopathy in trauma patients as well as the transformative effect tranexamic acid has had in limiting blood loss. We also explore some emerging technologies such as endovascular interventions and clot-stabilising dressings and devices that are likely to have a significant impact going forward.

Quality indicators in primary elective total hip and knee arthroplasty.

PURPOSE: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation. METHODS: A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained. RESULTS: Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia. CONCLUSION: This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma.

Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.

Limiting Blood Loss in Orthopaedic Trauma: Strategies and Effects.

Trauma is a major cause of mortality globally, with post-traumatic hemorrhage being the leading cause of death amongst trauma patients. In this paper, the authors review the underlying pathophysiology of trauma-related hemorrhagic shock, specifically the factors which contribute to the development of the acute coagulopathy of trauma shock (ACoTS). We then review the best available evidence for treatment strategies in the pre-hospital setting, as well as the in-hospital setting. Interventions that are strongly supported in the literature include utilization of a well-organized trauma system with direct transport to a designated trauma centre, the early use of tranexamic acid, and damage control orthopaedic surgical techniques and resuscitation protocols. Targeted resuscitation is an evolving field, with use of thromboelastography to guide resuscitation being a particularly promising area. Special trauma populations at particularly high risk are also reviewed, including the geriatric population, as well as unstable pelvic fractures, which are each at increased risk for poor outcomes, and deserve special attention. Major advances have been made in this important area, and ongoing research into the understanding and correction of ACoTS will continue to guide practice.

Hip fracture care and national systems: The United States and Canada.

While it is widely understood that management of hip fractures not only represents clinical decision making dilemmas for the individual orthopaedist, these increasingly common injuries present economic burdens to local and national systems as well. This supplement article looks at current clinical trends, as well as systems-based issues in the United States and Canada.

Synthetic Graft Compared With Allograft Reconstruction for Extensor Mechanism Disruption in Total Knee Arthroplasty: A Multicenter Cohort Study.

BACKGROUND: Extensor mechanism disruption after total knee arthroplasty is a serious complication leading to notable patient morbidity. The purpose of this study is to compare the outcomes of extensor mechanism allograft with synthetic graft reconstruction. METHODS: We retrospectively identified all patients who underwent extensor mechanism reconstruction using either allograft or synthetic graft from two high-volume academic arthroplasty institutions between 2006 and 2017. We collected extensor lag, need for ambulatory aids, and patient-reported outcome measures, as well as the incidence of postoperative complications and revision surgeries. We evaluated cost differences, considering both material cost and the need for revision surgery. RESULTS: We identified 27 cases. A significantly greater postoperative extensor lag was found in the allograft group (P = 0.05). Graft failure after synthetic reconstruction was zero, with an overall revision surgery rate of 15%. Graft failure was 21%, and the revision surgery rate was 43% after allograft reconstruction. The allograft cost was significantly higher compared with the synthetic graft cost (P = 0.001). The mean total cost was 4,733.08 CAD for the synthetic group and 24,050.40 CAD for the allograft group (P = 0.17). DISCUSSION: Synthetic reconstruction for extensor mechanism disruption shows benefit in postoperative extensor lag, graft failure, revision surgery, and cost when compared with allograft. LEVEL OF EVIDENCE: Level III.

Comparative fixation of tibial plateau fractures using alpha-BSM, a calcium phosphate cement, versus cancellous bone graft.

OBJECTIVES: To compare the compressive strength of a bone substitute material (alpha-BSM) to cancellous bone when used to fill a defect void in a cadaver model of a Schatzker II split depression fracture of the lateral tibial plateau. DESIGN: Randomized, paired design. SETTING: Biomedical engineering laboratory. PATIENTS: Twenty-six human tibias were harvested from 13 cadavers. Three pairs of tibia fractured during preparation and were excluded. The remaining 10 matched pairs were randomized to fixation by using the bone substitute material or cancellous bone. INTERVENTION: A split depression fracture of the lateral tibial plateau was created in each tibia by using reproducible methods. This fracture was stabilized with a stainless steel L-plate and screws and either alpha-BSM or cancellous bone to fill the defect void. MAIN OUTCOME MEASUREMENTS: Stiffness of the elevated fragment in compression, total depression of the joint at 1000 N. RESULTS: The alpha-BSM bone substitute displayed significantly greater stiffness than cancellous bone constructs in Schatzker II split depression fractures of the lateral tibial plateau (P < 0.0001). Plateau defects displaced significantly less at 1000 N when using alpha-BSM in comparison to cancellous bone (P < 0.0001). CONCLUSIONS: In this cadaveric study, alpha-BSM is an effective bone substitute compared with cancellous bone graft for stabilizing split depression fractures of the lateral tibial plateau.