Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Effect of split posterior tibialis tendon transfer on foot progression angle in children with cerebral palsy

OBJECTIVES

A common orthopedic issue for patients with spastic cerebral palsy (CP) is hindfoot varus deformity. One method of treatment is the split posterior tibialis tendon transfer (SPOTT). There is limited literature on the effect of SPOTT on foot progression angle (FPA) in children with CP who have equinovarus deformities. The objective of our study was to evaluate the change in FPA after SPOTT to determine if this procedure can improve FPA.

RESEARCH QUESTION

This study aims to determine what axial changes are generated from a split posterior tibial tendon transfer in children with CP.

METHODS

We performed a retrospective analysis of all ambulatory children with a diagnosis of CP who underwent SPOTT at our institution. Patients with bony rotational procedures were excluded. Descriptive statistics including mean and standard deviation (SD) were used to characterize continuous variables. Paired t-tests were used to evaluate outcomes, in which a target outcome was defined as a post-operative FPA between 0-10° of external rotation.

RESULTS

44 limbs were included. Demographics were as follows: 26/13 female/male; mean age[SD] (years): 9.8[3.5]; 30 hemiplegic, 9 diplegic, and 1 triplegic. Of the 44 limbs, 18 limbs had a target outcome, 4 had no change, and 22 had a non-target outcome. Of the 22 with an outcome outside of the target, 4 limbs trended away from a target outcome. The overall change in FPA measured was - 10.9 ± 14.7° (p < 0.0001) Age at time of surgery, CP involvement, pre-operative FPA, and GMFCS level were not predictors of outcome (p > 0.05).

CONCLUSIONS

SPOTT produced a change of 10.9° external rotation in FPA post-operatively and its effects should be considered when planning a SEMLS.

Quantitative measures of motor development in Angelman syndrome

Angelman Syndrome is a rare neurodevelopmental disorder characterized by developmental delay, lack of speech, seizures, intellectual disability, characteristic behavior, and movement disorders. Clinical gait analysis provides the opportunity for movement quantification to investigate an observed maladaptive change in gait pattern and offers an objective outcome of change. Pressure-sensor-based technology, inertial and activity monitoring, and instrumented gait analysis (IGA) were employed to define motor abnormalities in Angelman syndrome. Temporal-spatial gait parameters of persons with Angelman Syndrome (pwAS) show deficiencies in gait performance through walking speed, step length, step width, and walk ratio. pwAS walk with reduced step lengths, increased step width, and greater variability. Three-dimensional motion kinematics showed increased anterior pelvic tilt, hip flexion, and knee flexion. PwAS have a walk ratio more than two standard deviations below controls. Dynamic electromyography showed prolonged activation of knee extensors, which was associated with a decreased range of motion and the presence of hip flexion contractures. Use of multiple gait tracking modalities revealed that pwAS exhibit a change in gait pattern to a flexed knee gait pattern.  Cross-sectional studies of individuals with AS show a regression toward this maladaptive gait pattern over development in pwAS ages 4-11. PwAS unexpectedly did not have spasticity associated with change in gait pattern. Multiple quantitative measures of motor patterning may offer early biomarkers of gait decline consistent with critical periods of intervention, insight into appropriate management strategies, objective primary outcomes, and early indicators of adverse events.

Rectus femoris transfers with and without a hamstring lengthening will not change hip kinematics in children with cerebral palsy

BACKGROUND

A rectus femoris transfer (RFT) surgery with and without a hamstring lengthening (HSL) is used to treat stiff-knee gait in children with cerebral palsy (CP). While current literature has reported that a RFT surgery improves the kinematics at the knee, little is known about the kinematic changes at the hip.

RESEARCH QUESTION

Does a RFT surgery change hip joint kinematics in children with CP?

METHODS

This retrospective study included children (<18 years old) diagnosed with CP, who underwent a RFT procedure, and who were seen at our institution's accredited clinical motion laboratory. Patients with both pre- and post-operative gait analysis were identified and comparison between those analyses were performed to identify kinematic differences at the hip and knee. A total of 66 legs from 46 children (mean age: 11.1 ± 3.6) met the inclusion criteria.

RESULTS

Overall results revealed that a RFT did not change kinematics at the hip [p > 0.05], however, a RFT did increase the maximum knee flexion during the swing period [Mean Difference Post - Pre: 8.3°, 95% CI: 4.9-11.8, p < 0.0001]. Additionally, it was found that changes in hip extension during the terminal stance phase were significantly different between the combined RFT and HSL compared to solely an RFT. The results of this study also revealed that children whose stiff-knee gait did not improve, tended to have increased hip external rotation during terminal stance and swing and greater hip extension during terminal stance, compared to children whose stiff-knee gait did improve.

SIGNIFICANCE

Overall, a RFT with and without a HSL surgery improves hip and knee kinematics in the sagittal plane, however, improvements at the hip were not clinically significant. As a result, a RFT or a combined RFT with HSL should not be used to change hip kinematics in children with CP.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Experimental and theoretical rationalization for the base pairing abilities of inosine, guanosine, adenosine, and their corresponding 8-oxo-7,8-dihydropurine, and 8-bromopurine analogues within A-form duplexes of RNA

Inosine is an important RNA modification, furthermore RNA oxidation has gained interest due, in part, to its potential role in the development/progression of disease as well as on its impact on RNA structure and function. In this report we established the base pairing abilities of purine nucleobases G, I, A, as well as their corresponding, 8-oxo-7,8-dihydropurine (common products of oxidation at the C8-position of purines), and 8-bromopurine (as probes to explore conformational changes), derivatives, namely 8-oxoG, 8-oxoI, 8-oxoA, 8-BrG, and 8-BrI. Dodecamers of RNA were obtained using standard phosphoramidite chemistry via solid-phase synthesis, and used as models to establish the impact that each of these nucleobases have on the thermal stability of duplexes, when base pairing to canonical and noncanonical nucleobases. Thermal stabilities were obtained from thermal denaturation transition (Tm ) measurements, via circular dichroism (CD). The results were then rationalized using models of base pairs between two monomers, via density functional theory (DFT), that allowed us to better understand potential contributions from H-bonding patterns arising from distinct conformations. Overall, some of the important results indicate that: (a) an anti-I:syn-A base pair provides thermal stability, due to the absence of the exocyclic amine; (b) 8-oxoG base pairs like U, and does not induce destabilization within the duplex when compared to the pyrimidine ring; (c) a U:G wobble-pair is only stabilized by G; and (d) 8-oxoA displays an inherited base pairing promiscuity in this sequence context. Gaining a better understanding of how this oxidatively generated lesions potentially base pair with other nucleobases will be useful to predict various biological outcomes, as well as in the design of biomaterials and/or nucleotide derivatives with biological potential.

7,8-Dihydro-8-oxoguanosine Lesions Inhibit the Theophylline Aptamer or Change Its Selectivity

Aptamers are attractive constructs due to their high affinity/selectivity towards a target. Here 7,8-dihydro-8-oxoguanosine (8-oxoG) has been used, due in part to its unique H-bonding capabilities (Watson-Crick or Hoogsteen), to expand the "RNA alphabet". Its impact on the theophylline RNA aptamer was explored by modifying its binding pocket at positions G11, G25, or G26. Structural probing, with RNases A and T1 , showed that modification at G11 leads to a drastic structural change, whereas the G25-/G26-modified analogues exhibited cleavage patterns similar to that of the canonical construct. The recognition properties towards three xanthine derivatives were then explored through thermophoresis. Modifying the aptamer at position G11 led to binding inhibition. Modification at G25, however, changed the selectivity towards theobromine (Kd ≈160 μm), with a poor affinity for theophylline (Kd >1.5 mm) being observed. Overall, 8-oxoG can have an impact on the structures of aptamers in a position-dependent manner, leading to altered target selectivity.

Through babies' eyes: Practical and theoretical considerations of using wearable technology to measure parent-infant behaviour from the mothers' and infants' view points

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Ecologically valid measurement of mother–infant behaviour is difficult.

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Observations often rely on short snapshots with a researcher present.

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Wearable cameras can be worn by mothers and infants alone at home.

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Home interactions were compared with an observation with a researcher.

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More negative maternal behaviour was recorded using ‘headcams’ alone.

Aims

To explore the utility of first-person viewpoint cameras at home, for recording mother and infant behaviour, and for reducing problems associated with participant reactivity, which represent a fundamental bias in observational research.

Methods

We compared footage recording the same play interactions from a traditional third-person point of view (3rd PC) and using cameras worn on headbands (first-person cameras [1st PCs]) to record first-person points of view of mother and infant simultaneously. In addition, we left the dyads alone with the 1st PCs for a number of days to record natural mother–child behaviour at home. Fifteen mothers with infants (3–12 months of age) provided a total of 14 h of footage at home alone with the 1st PCs.

Results

Codings of maternal behaviour from footage of the same scenario captured from 1st PCs and 3rd PCs showed high concordance (kappa >0.8). Footage captured by the 1st PCs also showed strong inter-rater reliability (kappa = 0.9). Data from 1st PCs during sessions recorded alone at home captured more ‘negative’ maternal behaviours per min than observations using 1st PCs whilst a researcher was present (mean difference = 0.90 (95% CI 0.5–1.2, p < 0.001 representing 1.5 SDs).

Conclusion

1st PCs offer a number of practical advantages and can reliably record maternal and infant behaviour. This approach can also record a higher frequency of less socially desirable maternal behaviours. It is unclear whether this difference is due to lack of need of the presence of researcher or the increased duration of recordings. This finding is potentially important for research questions aiming to capture more ecologically valid behaviours and reduce demand characteristics.

Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care

The last fifteen years have seen a dramatic increase in both the childbearing age and diversity of women migrating to Canada. The resulting health impact underscores the need to explore access to health services and the related maternal health outcome. This article reports on the results of a scoping review focused on migrant maternal health within the context of accessible and effective health services during pregnancy and following delivery. One hundred and twenty-six articles published between 2000 and 2016 that met our inclusion criteria and related to this group of migrant women, with pregnancy/motherhood status, who were living in Canada, were identified. This review points at complex health outcomes among immigrant and refugee women that occur within the compelling gaps in our knowledge of maternal health during all phases of maternity. Throughout the prenatal, intrapartum, and postnatal periods of maternity, barriers to accessing healthcare services were found to disadvantage immigrant and refugee women putting them at risk for challenging maternal health outcomes. Interactions between the uptake of health information and factors related to the process of immigrant settlement were identified as major barriers. Availability of appropriate services in a country that provides universal healthcare is discussed.

Texture analysis of periventricular echogenicity on neonatal cranial ultrasound predicts periventricular leukomalacia

BACKGROUND

White matter periventricular echogenicity detected in neonatal cranial ultrasound (US) scans may be followed by cystic periventricular leukomalacia (PVL) or might resolve. Serial US are therefore needed to clarify the outcome. Texture analysis is a computerized method to analyze images and distinguish findings that are undetectable by the human eye.

OBJECTIVE

To test whether texture analysis can differentiate echogenicities that resolve from those that develop cystic PVL.

MATERIAL AND METHODS

Neonates with echogenicities on their initial US scan were studied; texture analysis was performed on the coronal and sagittal sections. Texture parameters were entered into a linear discriminant analysis (LDA) to classify the scans along two axes called most discriminant features (MDF) 1 and 2.

RESULTS

We studied twenty infants with periventricular echogenicities on initial scans; ten of them later resolved (group A), while the other ten infants developed cystic PVL (group B). The classification accuracy was 66% and 82% for group A and B on sagittal sections, and 75%, and 80% on coronal. In the coronal and sagittal plane respectively, a MDF1 value of 0.98 and 0.24 and an MDF2 value of 0.86 and 0.001 provided the best sensitivity, specificity, positive and negative likelihood ratio.

CONCLUSION

Texture analysis is a promising objective tool to early identify which cranial echogenicity that will develop into cystic PVL.

Electronic Health Record Adoption - Maybe It's not about the Money: Physician Super-Users, Electronic Health Records and Patient Care

OBJECTIVE

The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue.

METHODS

Two EHR systems were examined - the paperless VistA / Computerized Patient Record System used at the Veterans' Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity.

RESULTS

Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR's are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR's had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians' needs.

CONCLUSION

Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.

Overweight and obesity in pregnancy do not adversely affect neonatal outcomes: new evidence

We studied neonatal outcomes of infants of obese mothers in a cohort of 6,125 deliveries, using logistic multivariate analysis to remove the role of potential confounding variables. Although, as in previous reports, the crude unadjusted prevalence of several adverse neonatal outcomes was higher in these infants, the multivariable analysis revealed that only two outcomes remained significantly associated with maternal overweight and obesity: neonatal macrosomia (adjusted odds ratios aOR 1.4, p < 0.001) and meconium aspiration syndrome (aOR 1.6, p = 0.05), indicating that the unadjusted association with the other outcomes was caused by confounding factors. Nonetheless, as macrosomia is associated with increased health risks both to the mothers and their infants, and maternal obesity with considerable maternal morbidity during pregnancy, these results should not lead to complacency, but instead encourage better prevention of obesity in general and during pregnancy in particular.

Infants of diabetic mothers with abnormal fetal growth missed by standard growth charts

Diabetic pregnancies may result in fetal macrosomia when glycaemia is poorly controlled, and when associated with diabetic vasculopathy, with small for gestational age (SGA) neonates. Both groups of infants have high neonatal morbidity. As fetal growth depends on maternal genetic influences, ethnic group or parity, relying exclusively on population-based growth charts may wrongly categorise the growth pattern of these infants. We compared neonatal morbidity and mortality of a cohort of 214 infants of diabetic mothers (IDM), identified either by population standards or by customised birth weight percentiles (adjusted for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and sex). A total of 68 (31.8%) were diagnosed with macrosomia, 11 (16%) of whom were identified by the customised growth method alone, and 16 were diagnosed as SGA (7.5%), of whom the majority (13 or 81.2%) were identified by the customised growth method alone. None had increased mortality and morbidity.