Hospital variation in quality indicators for patient blood management in total knee and hip arthroplasty: a retrospective cohort study.

BACKGROUND: Anaemia, blood loss, and blood transfusion are critical aspects of patient care in major orthopaedic surgery. We assessed hospital adherence to guideline-recommended Patient Blood Management (PBM) care, analysed variations between hospitals, and validated two composite indicators of hospital PBM performance in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS: This retrospective cohort study included all primary TKA and THA procedures performed during 2021 across 39 hospitals in Spain. We assessed hospital adherence to key guideline-recommended PBM interventions using nine individual quality indicators and two types of composite quality indicators (cQIs): opportunity-based (cQI1) and all-or-none (cQI2). We validated these cQIs by analysing their associations with the adjusted total transfusion index using linear regression. RESULTS: We included 8561 patient episodes from 33 hospitals in the analysis. Delivery of PBM care was similar for TKA and THA. Patients received 62% of the analysed PBM interventions and only 12% of patients underwent the full PBM pathway. Higher hospital cQIs scores were associated with a lower adjusted total transfusion index, both in TKA and THA. The greatest association was found for cQI1 in THA patients (ß=-1.18 [95% confidence interval -2.00 to -0.36]; P=0.007). CONCLUSIONS: Hospital adherence to guideline-recommended patient blood management care in total hip and knee arthroplasty was suboptimal and varied across centres. Using data that are widely available in hospitals, quality indicators and composite scores could become valuable tools for patient blood management monitoring and comparisons between healthcare organisations.

Associations between postoperative anaemia and unplanned readmission to hospital after major surgery: a retrospective cohort study†.

BACKGROUND: Anaemia following major surgery may be associated with unplanned readmission to hospital. However, the severity-response relationship between the degree of anaemia at discharge and the risk of unplanned readmission is poorly defined. We aimed to describe the severity-response relationship between haemoglobin concentration at the time of discharge and the risk of unplanned readmission in a cohort of patients undergoing different types of major surgery. METHODS: We performed a retrospective cohort study in a single tertiary health service, including all patients who underwent major surgery (orthopaedic, abdominal, cardiac or thoracic) between 1 May 2011 and 1 February 2022. The primary outcome was unplanned readmission to hospital in the 90 days following discharge after the index surgical procedure. These complex, non-linear relationships were modelled with restricted cubic splines. RESULTS: We identified 22,134 patients and included 14,635 in the primary analysis, of whom 1804 (12%) experienced at least one unplanned readmission. The odds of unplanned readmission rose when the discharge haemoglobin concentration was < 100 g.l-1 (p < 0.001). On subgroup analysis, the haemoglobin threshold below which odds of readmission began to increase appeared to be higher in patients undergoing emergency surgery (110 g.l-1; p < 0.001) compared with elective surgery. Declining discharge haemoglobin concentration was associated with increased odds ratios (95%CI) of unplanned readmission in patients undergoing orthopaedic (1.08 (1.01-1.15), p = 0.03), abdominal (1.13 (1.07-1.19), p < 0.001) and thoracic (1.12 (1.01-1.24), p = 0.03) procedures, but not cardiac surgery (1.09 (0.99-1.19), p = 0.07). CONCLUSIONS: Our findings suggest that a haemoglobin concentration < 100 g.l-1 following elective procedures and < 110 g.l-1 following emergency procedures, at the time of hospital discharge after major surgery, was associated with unplanned readmission. Future interventional trials that aim to treat postoperative anaemia and reduce unplanned readmission should include patients with discharge haemoglobin below these thresholds.

Prevention of thromboembolism after a fracture: is aspirin enough?

Venous thromboembolism (VTE) is a serious complication that can arise during and after hospitalization, particularly following surgery under general anaesthesia. Particularly at risk are major orthopaedic surgical procedures such as elective knee or hip replacement and the treatment of hip fractures. In these patients, current guidelines recommend (low or low-moderate level of evidence) aspirin as a possible alternative to anticoagulant therapy for the prophylaxis of long-term venous thromboembolism after an initial period with anticoagulant drugs. Several randomized trials and meta-analyses demonstrate no significant differences in the risk of VTE when comparing aspirin with anticoagulants. However, it must be considered that most recommendations are based on elective orthopaedic surgery and that trials after fractures have excluded patients at high thrombotic risk. Consequently, the overall incidence of major clinical events (death and pulmonary embolism) was ∼1% with wide confidence margins in even large non-inferiority studies. The incidence of asymptomatic VTE, especially distal, appears to be higher with aspirin. Patient preference and lower costs could play an important role in the choice in favour of aspirin.

Surgeon variation: a south african spinal pathology treatment survey.

PURPOSE: To investigate variation in treatment decisions among spine surgeons in South Africa and the association between surgeon characteristics and the treatment they select. METHODS: We surveyed 79 South African spine surgeons. We presented four vignettes (cervical spine distractive flexion injury, lumbar disc herniation, degenerative spondylolisthesis with stenosis, and insufficiency fracture) for them to assess and select treatments. We calculated the index of qualitative variation (IQV) to determine the degree of variability within each vignette. We used Fisher's exact, and Kruskal-Wallis tests to assess the relationships between surgeons' characteristics and their responses per vignette. We compared their responses to the recommendations of a panel of spine specialists. RESULTS: IQVs showed moderate to high variability for cervical spine distractive flexion injury and insufficiency fracture and slightly lower levels of variability for lumbar disc herniation and degenerative spondylolisthesis with stenosis. This confirms the heterogeneity in South African spine surgeons' management of spinal pathologies. The surgeon characteristics associated with their treatment selection that were important were caseload, experience and training, and external funding. Also, 19% of the surgeons selected a treatment option that the Panel did not support. CONCLUSION: The findings make a case for evaluating patient outcomes and costs to identify value-based care. Such research would help countries that are seeking to contract with providers on value. Greater uniformity in treatment and easily accessible outcomes reporting would provide guidance for patients. Further investment in training and participation in fellowship programs may be necessary, along with greater dissemination of information from the literature.

Application of robot navigation system for insertion of femoral neck system in the treatment of femoral neck fracture.

PURPOSE: To evaluate the short-term clinical efficacy and advantages of surgery robot positioning system for insertion of Femoral Neck System (FNS) in the treatment of femoral neck fractures. METHODS: The clinical data of 52 patients with Femoral neck fracture (FNF) who had been treated with FNS between June 2020 and September 2021 were retrospectively analyzed. Among them, 26 patients were treated with traditional FNS (control group), while 26 additional patients were treated with FNS assisted by an orthopaedic robot positioning system (study group). The operation duration, frequency of key-guide needle placement, intraoperative blood loss, incision length, fracture healing rate, fracture healing time, and the Harris scores at the last follow-up were calculated and compared between the 2 groups. RESULTS: The study group had shorter operation duration, fewer numbers of placing the key-guide needle, less intraoperative blood loss, and smaller surgical incisions than the control group (all, P < 0.05). There was no significant difference in the rate of fracture healing rate between the 2 groups (P = 0.47), while the fracture healing duration of the study group was shorter than that of the control group (P = 0.03). At the last follow-up, compared with the control group, the Harris score and the number of excellent and good ratings were significantly higher in the study group (all, P < 0.05). CONCLUSIONS: Using orthopaedic surgery robot positioning system-assisted FNS in the treatment of FNFs can effectively improve the efficiency of surgery, shorten operation time, and reduce the number of placing the key-guide needle, intraoperative blood loss, and operative trauma. Simultaneously, it shortens the duration of fracture healing and improves the recovery of hip function.

A practical guide to the development and deployment of deep learning models for the orthopaedic surgeon: Part III, focus on registry creation, diagnosis, and data privacy.

Deep learning is a subset of artificial intelligence (AI) with enormous potential to transform orthopaedic surgery. As has already become evident with the deployment of Large Language Models (LLMs) like ChatGPT (OpenAI Inc.), deep learning can rapidly enter clinical and surgical practices. As such, it is imperative that orthopaedic surgeons acquire a deeper understanding of the technical terminology, capabilities and limitations associated with deep learning models. The focus of this series thus far has been providing surgeons with an overview of the steps needed to implement a deep learning-based pipeline, emphasizing some of the important technical details for surgeons to understand as they encounter, evaluate or lead deep learning projects. However, this series would be remiss without providing practical examples of how deep learning models have begun to be deployed and highlighting the areas where the authors feel deep learning may have the most profound potential. While computer vision applications of deep learning were the focus of Parts I and II, due to the enormous impact that natural language processing (NLP) has had in recent months, NLP-based deep learning models are also discussed in this final part of the series. In this review, three applications that the authors believe can be impacted the most by deep learning but with which many surgeons may not be familiar are discussed: (1) registry construction, (2) diagnostic AI and (3) data privacy. Deep learning-based registry construction will be essential for the development of more impactful clinical applications, with diagnostic AI being one of those applications likely to augment clinical decision-making in the near future. As the applications of deep learning continue to grow, the protection of patient information will become increasingly essential; as such, applications of deep learning to enhance data privacy are likely to become more important than ever before. Level of Evidence: Level IV.

Prior Bariatric Surgery is Associated with Improved Total Hip Arthroplasty Outcomes in Patients Who Have Obesity: A National Cohort Study with 6 Years of Follow-Up.

BACKGROUND: Obesity is a risk factor for end-stage hip osteoarthritis (OA). While total hip arthroplasty (THA) is commonly performed to reduce pain and improve function associated with OA, obesity has been associated with an increased risk of complications after THA. Although bariatric surgery may also be utilized to reduce weight, the impact of bariatric surgery on THA outcomes remains inadequately understood. METHODS: This retrospective cohort analysis utilized multicenter electronic medical record data ranging from 2003 to 2023. Patients who have obesity who underwent THA were stratified based on prior bariatric surgery. The final bariatric cohort comprised 451 patients after propensity score matching. Complication rates and revision risks were compared between cohorts at six, 24, and 72 months. Additional analysis stratified patients by interval between bariatric surgery and THA. RESULTS: At six-month follow-up, the bariatric cohort had significantly lower risks of surgical site infection (SSI), wound dehiscence, and deep vein thrombosis (DVT). At 24 months, the bariatric cohort had a lower risk of DVT. At 72 month follow-up, the bariatric cohort had reduced rates of revision, mortality, cardiac morbidity, and Clavien-Dindo grade IV complications. CONCLUSION: Obese patients who underwent bariatric surgery prior to THA experienced reduced medical complications at all time points and reduced rates of revision at 72 months relative to a matched cohort who did not undergo bariatric surgery.

Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period. METHODS: We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests. RESULTS: Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low. CONCLUSIONS: The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

Pressure injury risk factors in adult orthopaedic surgical patients: a cross-sectional study and random forest.

OBJECTIVE: To identify the most important risk factors for predicting pressure injury (PI) occurrence in adult orthopaedic surgical patients based on investigation data, thereby identifying at-risk patients and facilitating formulation of an effective patient care strategy. METHOD: Patients were assessed with an instrument designed by the authors specifically for this study in a cross-sectional investigation following the STROBE checklist. The random forest method was adopted to select the most important risk factors and predict occurrence of PIs. RESULTS: A dataset of 27 risk factors from 1701 patients was obtained. A subset of the 15 most important risk factors was identified. The random forest method had a high prediction accuracy of 0.9733 compared with 0.9281 calculated with a logistic model. CONCLUSION: Results indicated that the selected 15 risk factors, such as activity ability, friction/shear force, skin type and anaesthesia score, performed very well in predicting the occurrence of PIs in adult orthopaedic surgical patients.

Systematic review of nerves at risk at the wrist in common surgical approaches to the forearm: Anatomical variations and surgical implications.

Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether 'safe zones' exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.

Standing on shoulder of giants: the incredible legacy of the Judet family in orthopaedic surgery.

In orthopaedic surgery, as well as other areas in medicine, it is common for a surgical technique to carry the original authors' name describing the procedure. The Judet family represents a unique history, since several orthopaedic procedures are known as "Judet's technique". The aim of this historic review is to outline the genealogy of the orthopaedic arm of the Judet family, while crediting each surgical procedure to the specific family member that described the technique.

The impact of early nutritional support on postoperative wound healing in patients with complex fractures: A meta-analysis review.

Complex fractures present significant challenges in orthopaedic surgery, particularly in terms of postoperative wound healing. Nutritional status plays a crucial role in the recovery process, with early nutritional support potentially influencing wound healing outcomes. This meta-analysis aimed to assess the impact of early nutritional interventions on postoperative wound healing and scar formation in patients with complex fractures. From an initial pool of 1742 articles, 7 studies were selected for analysis. The results revealed that preoperative nutritional support significantly improved early wound healing, as indicated by lower REEDA scores (SMD = -14.06, 95% CI: [-16.79, -11.32], p < 0.01) 1 week post-surgery. Furthermore, there was a notable reduction in scar formation, as demonstrated by lower Manchester Scar Scale scores (SMD = -25.03, 95% CI: [-30.32, -19.74], p < 0.01) 3 months post-surgery. These findings highlight the importance of incorporating nutritional strategies into the management of complex fractures to optimize postoperative recovery.

Effect of comprehensive nursing intervention on the formation of pressure sore in patients undergoing orthopaedic surgery in prone position.

Pressure ulcers are a common complication of prone orthopaedic surgery, causing pain and inconvenience to patients. This study aimed to evaluate a comprehensive nursing intervention for pressure ulcer formation in these patients. A total of 120 patients undergoing prone orthopaedic surgery were randomly divided into two groups. The study group (60 patients) received a comprehensive nursing intervention, whereas the control group (60 patients) received a routine nursing intervention. After 2 weeks, the comprehensive nursing intervention significantly reduced the incidence and degree of pressure sores and led to a shorter recovery time than the routine nursing intervention (p < 0.05). The incidence of postoperative wound complications was decreased, and patient satisfaction was significantly improved (p < 0.05). The Hamilton Anxiety Scale, Hamilton Depression Scale and visual analogue scale scores of the study group were significantly lower than those of the control group, and the Short Form 36 Health Survey Questionnaire scores were higher than those of the control group (p < 0.05). A comprehensive nursing intervention can significantly reduce the incidence and degree of pressure ulcers, accelerate recovery time, reduce postoperative wound complications and improve the quality of life and satisfaction of patients undergoing prone orthopaedic surgery.

Impact of perioperative enhanced recovery after surgery on wound infection in patients undergoing orthopaedic surgery: A meta-analysis.

The aim of this study was to evaluate the effects of perioperative application of enhanced recovery after surgery (ERAS) concepts on wound infections and post-operative complications in patients receiving orthopaedic surgery, to provide a theoretical basis for post-operative care. Randomised controlled trials (RCTs) on the application of ERAS to patients receiving orthopaedic surgery, published up to October 2023, were identified in PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure databases. Literature was screened and evaluated by two reviewers based on the inclusion and exclusion criteria, and data were extracted from the final included articles. Data were analysed using RevMan 5.4 software. A total of 20 RCTs were included in the analysis, which included 1875 patients undergoing orthopaedic surgery, of whom 938 and 937 were in the ERAS and control groups, respectively. The analysis revealed that in patients undergoing orthopaedic surgery, implementation of ERAS in the perioperative period was associated with a significantly reduced the rate of wound infections (1.6% vs. 6.19%, risk ratio [RR]: 0.30, 95% confidence interval [CI]: 0.18-0.50, p < 0.001) and complication (5.12% vs. 21.88%, RR: 0.23, 95% CI: 0.17-0.32, p < 0.001) and can effectively shorten the hospital length of stay (standardised mean difference [SMD]: -2.50 days, 95% CI: -3.17 to -1.83 days, p < 0.001) compared with that of conventional care. The available evidence suggests that the implementation of ERAS in the perioperative period of patients undergoing orthopaedic surgery could effectively reduce the rate of wound infections and complications, shorten the hospital length of stay and promote the early recovery of patients.

Evaluating ChatGPT responses in the context of a 53-year-old male with a femoral neck fracture: a qualitative analysis.

PURPOSE: The integration of artificial intelligence (AI) tools, such as ChatGPT, in clinical medicine and medical education has gained significant attention due to their potential to support decision-making and improve patient care. However, there is a need to evaluate the benefits and limitations of these tools in specific clinical scenarios. METHODS: This study used a case study approach within the field of orthopaedic surgery. A clinical case report featuring a 53-year-old male with a femoral neck fracture was used as the basis for evaluation. ChatGPT, a large language model, was asked to respond to clinical questions related to the case. The responses generated by ChatGPT were evaluated qualitatively, considering their relevance, justification, and alignment with the responses of real clinicians. Alternative dialogue protocols were also employed to assess the impact of additional prompts and contextual information on ChatGPT responses. RESULTS: ChatGPT generally provided clinically appropriate responses to the questions posed in the clinical case report. However, the level of justification and explanation varied across the generated responses. Occasionally, clinically inappropriate responses and inconsistencies were observed in the generated responses across different dialogue protocols and on separate days. CONCLUSIONS: The findings of this study highlight both the potential and limitations of using ChatGPT in clinical practice. While ChatGPT demonstrated the ability to provide relevant clinical information, the lack of consistent justification and occasional clinically inappropriate responses raise concerns about its reliability. These results underscore the importance of careful consideration and validation when using AI tools in healthcare. Further research and clinician training are necessary to effectively integrate AI tools like ChatGPT, ensuring their safe and reliable use in clinical decision-making.

Direct intraoperative measurement of isometric contractile properties in living human muscle.

Skeletal muscle's isometric contractile properties are one of the classic structure-function relationships in all of biology allowing for extrapolation of single fibre mechanical properties to whole muscle properties based on the muscle's optimal fibre length and physiological cross-sectional area (PCSA). However, this relationship has only been validated in small animals and then extrapolated to human muscles, which are much larger in terms of length and PCSA. The present study aimed to measure directly the in situ properties and function of the human gracilis muscle to validate this relationship. We leveraged a unique surgical technique in which a human gracilis muscle is transferred from the thigh to the arm, restoring elbow flexion after brachial plexus injury. During this surgery, we directly measured subject specific gracilis muscle force-length relationship in situ and properties ex vivo. Each subject's optimal fibre length was calculated from their muscle's length-tension properties. Each subject's PCSA was calculated from their muscle volume and optimal fibre length. From these experimental data, we established a human muscle fibre-specific tension of 171 kPa. We also determined that average gracilis optimal fibre length is 12.9 cm. Using this subject-specific fibre length, we observed an excellent fit between experimental and theorical active length-tension curves. However, these fibre lengths were about half of the previously reported optimal fascicle lengths of 23 cm. Thus, the long gracilis muscle appears to be composed of relatively short fibres acting in parallel that may not have been appreciated based on traditional anatomical methods. KEY POINTS: Skeletal muscle's isometric contractile properties represent one of the classic structure-function relationships in all of biology and allow scaling single fibre mechanical properties to whole muscle properties based on the muscle's architecture. This physiological relationship has only been validated in small animals but is often extrapolated to human muscles, which are orders of magnitude larger. We leverage a unique surgical technique in which a human gracilis muscle is transplanted from the thigh to the arm to restore elbow flexion after brachial plexus injury, aiming to directly measure muscles properties in situ and test directly the architectural scaling predictions. Using these direct measurements, we establish human muscle fibre-specific tension of ∼170 kPa. Furthermore, we show that the gracilis muscle actually functions as a muscle with relatively short fibres acting in parallel vs. long fibres as previously assumed based on traditional anatomical models.

A bifactor model supports unidimensionality of the International Knee Documentation Committee Subjective Knee Form in young active patients with anterior cruciate ligament tears: a retrospective analysis of a randomized controlled trial.

BACKGROUND: The International Knee Documentation Committee Subjective Knee Form (IKDC) is the most highly recommended patient reported outcome measure for assessing patients with anterior cruciate ligament (ACL) injuries and those undergoing ACL reconstruction (ACLR) surgery. The IKDC was developed as a unidimensional instrument for a variety of knee conditions. Structural validity, which determines how an instrument is scored, has not been definitively confirmed for the IKDC in respondents with ACL injuries, and in fact an alternative two-factor/subscale structure has been proposed in this population. The purpose of this study was to determine the most appropriate structure and scoring system for the IKDC in young active patients following ACL injury. METHODS: In total, 618 young patients deemed at high risk of graft rupture were randomized into the Stability 1 trial. Of the trial participants, 606 patients (98%) completed a baseline IKDC questionnaire used for this analysis. A cross sectional retrospective secondary data analysis of the Stability 1 baseline IKDC data was completed to assess the structural validity of the IKDC using exploratory and confirmatory factor analyses. Factor analyses were used to test model fit of the intended one-factor structure, a two-factor structure, and alternative four-factor and bifactor structures (i.e., a combination of a unidimensional factor with additional specific factors) of the IKDC, in a dataset of young active ACL patients. RESULTS: The simple one-factor and two-factor structures of the IKDC displayed inadequate fit in our dataset of young ACL patients. A bifactor model provided the best fit. This model contains one general factor that is substantially associated with all items, plus four secondary, more specific content factors (symptoms, activity level, activities of daily living, and sport) with generally weaker associations to subsets of items. Although the single-factor model did not provide unambiguous support to unidimensionality of the IKDC based on fit indices, the bifactor model supports unidimensionality of the IKDC when covariance between items with similar linguistic structure, response options, or content are acknowledged. CONCLUSIONS: Overall, findings of a bifactor model with evidence of a reliable general factor well defined by all items lends support to continue interpreting and scoring this instrument as unidimensional. This should be confirmed in other samples. Clinically, based on these findings, the IKDC can be represented by a single score for young active patients with ACL tears. A more nuanced interpretation would also consider secondary factors such as sport and activity level. TRIAL REGISTRATION: The Stability 1 trial for which these data were collected was registered on ClinicalTrial.gov (NCT02018354).

Effect of transauricular nerve stimulation on perioperative pain: a single-blind, analyser-masked, randomised controlled trial.

BACKGROUND: Activation of central autonomic pathways, including those regulating the arterial baroreflex, might reduce acute pain. We tested the hypothesis that transcutaneous auricular nerve stimulation (TAN) reduces pain after orthopaedic trauma surgery through autonomic modulation. METHODS: A total of 86 participants aged >18 yr were randomly assigned to 50 min of either sham or active bilateral TAN, undertaken before, and again 24 h after, surgery for orthopaedic trauma. The primary outcome was absolute change in pain 24 h postoperatively, comparing the 100 mm visual analogue scale (VAS) before and after TAN. Secondary outcomes included the minimal clinically important difference in pain (>10 mm increase or reduction in VAS) before/after surgery, using intention-to-treat analysis. Holter monitoring, the analysis of which was masked to allocation, quantified autonomic modulation of heart rate. RESULTS: From June 22, 2021 to July 7, 2022, 79/86 participants (49 yr; 45% female) completed TAN before and after surgery. For the primary outcome, the mean reduction in VAS was 19 mm (95% confidence interval [CI]: 12-26) after active TAN (n=40), vs 10 mm (95% CI: 3-17) after sham TAN (n=39; P=0.023). A minimally clinically important reduction in postoperative pain occurred in 31/40 (78%) participants after active TAN, compared with 15/39 (38%) allocated to sham TAN (odds ratio 5.51 [95% CI: 2.06-14.73]; P=0.001). Only active TAN increased heart rate variability (log low-frequency power increased by 0.19 ms2 [0.01-0.37 ms2]). Prespecified adverse events (auricular skin irritation) occurred in six participants receiving active TAN, compared with two receiving sham TAN. CONCLUSION: Bilateral TAN reduces perioperative pain through autonomic modulation. These proof-of-concept data support a non-pharmacological, generalisable approach to improve perioperative analgesia.

Temporal changes and predictors of perioperative blood transfusion in elective spine surgery: a retrospective analysis of a large surgical database.

BACKGROUND: Allogeneic blood transfusion used to be common in spine surgery. Patient blood management has been widely adopted, and it is important to reassess transfusion predictors in contemporary practice. METHODS: A retrospective study of inpatient spine surgery was performed using National Surgical Quality Improvement Program (NSQIP) data from 2011 to 2019. The primary outcome was perioperative transfusion within 72 h of surgery. Multivariable logistic regression and recursive partitioning were used to assess up to 15 variables including patient and surgical data, surgical specialty (orthopaedic surgery vs neurosurgery), and year of surgery. RESULTS: The study population included 251 971 US surgical patients; 6.9% of these patients received perioperative blood transfusion. Perioperative transfusions declined over time with the steepest decline from 2011 to 2015. The greatest reduction was seen among orthopaedic cases where the transfusion rate declined from 16.0% to 8.7% between 2011 and 2015. Eight variables were predictive factors in a reduced model: operative time, preoperative haemoglobin, vertebral level, number of vertebral levels, older age, surgeon specialty, arthrodesis, and year of surgery (area under the curve [AUC]=0.880; 95% confidence interval [CI], 0.878-0.883). Overall, longer operative time (>144 min) and greater numbers of vertebral levels had greater associations with transfusion than surgical specialty after adjustments. Prevalence of anaemia (15%) has not substantially declined. CONCLUSIONS: Perioperative blood transfusion rate in spine surgery has declined over the past decade. The extent and duration of surgery and preoperative haemoglobin level remain important factors associated with increased odds for perioperative blood transfusion.