Is There a Consensus on Air Travel Following Hip and Knee Arthroplasty?

Introduction "When can I fly after my hip or knee replacement?" is a question frequently encountered by surgeons. Both air travel and arthroplasty increase the risk of venous thromboembolism (VTE); however, few studies examine the risk of air travel following arthroplasty. This study aimed to review the advice given to patients by surgeons, airlines, and insurance providers about flying after arthroplasty. We also review the current literature and available guidelines. Materials and methods A survey was sent to consultants with a special interest in hip or knee arthroplasty at 14 hospital trusts in the United Kingdom (UK) asking how long they would advise patients to avoid flying after surgery. We contacted all UK commercial airlines asking if they imposed any limitations on flying after arthroplasty. We contacted 15 UK insurance providers to determine whether they would provide insurance coverage following arthroplasty. Results A total of 110 knee surgeons and 105 hip surgeons were contacted. The response rate was 42% for hip surgeons and 44% for knee surgeons. Advised time to avoid flying varied widely from 14 to 180 days. A total of 22 airlines were contacted, and the response rate was 63% (n=14). Five airlines would not allow passengers to fly following arthroplasty and seven airlines required certification from a doctor. Fifteen insurance providers were contacted and the response rate was 73% (n=11). Seven insurance providers had restrictions on providing cover to passengers after arthroplasty. Conclusion Advice given to patients by surgeons, airlines, and insurance providers about flying following arthroplasty varies greatly. There is an absence of evidence-based guidelines to inform such advice. Further study is required to provide the evidence on which to base such advice. Therefore, we recommend that surgeons exercise caution when providing advice to patients.

Collaborative Team Training in Virtual Reality is Superior to Individual Learning For Performing Complex Open Surgery: A Randomized Controlled Trial.

OBJECTIVE: To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery. BACKGROUND: Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated. METHODS: Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors. RESULTS: Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001). CONCLUSIONS: Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.

Short term clinical and patient reported outcomes following Virtual Fracture Clinic management of fifth metatarsal fractures.

INTRODUCTION: Fracture clinics are experiencing increased referrals and decreased capacity. Virtual fracture clinics (VFC) are an efficient, safe, and cost-effective solution for specified injury presentations. There is currently a lack of evidence to support the use of a VFC model in the management of 5th metatarsal base fractures. This study aims to assess clinical outcomes and patient satisfaction with the management of 5th metatarsal base fractures in VFC. We hypothesise that it is both safe and cost effectiveness. METHODS: Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture, between January 2019 and December 2019, were included. Patient demographics, clinic appointments, complication and operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing, rehabilitation information and instructions to contact VFC if symptoms of pain persist after 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. A basic cost analysis was performed. RESULTS: 126 patients met inclusion criteria. Mean age was 41.6 years (18-92). Average time from ED attendance to VFC review was 2 days (1 - 5). Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 (6%) zone 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; pain the reason in all cases. There was 1 non-union during the study period. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scoring more than 0. In total, 248 face-to-face clinic visits were saved. CONCLUSION: Our experience demonstrates that the management of 5th metatarsal base fractures in the VFC setting, with a well-defined protocol, can prove safe, efficient, cost effective and yield good short term clinical outcomes.

The accuracy of statistical shape models in predicting bone shape: A systematic review.

BACKGROUND: This systematic review aims to ascertain how accurately 3D models can be predicted from two-dimensional (2D) imaging utilising statistical shape modelling. METHODS: A systematic search of published literature was conducted in September 2022. All papers which assessed the accuracy of 3D models predicted from 2D imaging utilising statistical shape models and which validated the models against the ground truth were eligible. RESULTS: 2127 papers were screened and a total of 34 studies were included for final data extraction. The best overall achievable accuracy was 0.45 mm (root mean square error) and 0.16 mm (average error). CONCLUSION: Statistical shape modelling can predict detailed 3D anatomical models from minimal 2D imaging. Future studies should report the intended application domain of the model, the level of accuracy required, the underlying demographics of subjects, and the method in which accuracy was calculated, with root mean square error recommended if appropriate.

Blood loss and transfusion rates following total hip arthroplasty: a multivariate analysis.

This study aimed to identify factors that inde- pendently predict increased rates of transfusion following total hip arthroplasty (THA) surgery. A retrospective analysis of all patients undergoing THA surgery over 12 months was performed. Electronic operative records were analysed to determine the following patient factors: American Society of Anesthesiologists (ASA) grade, body mass index (BMI), co-morbidities, indication for surgery, surgical technique, type of implant used, haematological markers, hospital length of stay (LOS) and complications. A total of 244 patients were included. There were 141 females (58%) and 103 males (42%). The median age was 65±12. The median pre-operative blood volume was 4500mls (IQR; 4000-5200). The median blood loss was 1069mls (IQR; 775-1390). The total number of patients requiring transfusion was 28 (11%), with a median of two units being transfused. Pre-operative haemoglobin (p<0.001) level, haematocrit (p<0.001) level and weight (p=0.016) were found to be predictive of transfusion requirement as well as ASA grade (p=0.005). Application of an intra-operative surgical drain was associated with higher rates of transfusion (p<0.001). Our study strengthens the evidence that pre-operative haemoglobin and haematocrit levels are valuable predictors of patients requiring transfusion. Additionally, ASA grade may be viewed as a helpful factor in predicting risk of transfusion. A strategy incorporating pre-operative optimisation of modifiable factors may reduce rates of transfusion requirement.

Shah-Waardenburg syndrome: a case highlighting the importance of a holistic approach to assessing a child.

We present the case of a 45-day-old child with the chief complaint of failure to pass stools for 10 days. After initial investigation, the patient was found to have Hirschsprung's disease. However, with further examination and analysis, the extremely rare diagnosis of type 4 Waardenburg syndrome was made (also known as Shah-Waardenburg syndrome or Waardenburg-Hirschsprung's disease).