Why Treat Patients with a Major Orthopaedic Surgery Only to Send Them Back to the Vulnerable Conditions That Made Them Sick in the First Place? A Conceptual Scenario to Improve Patient's Journey

Predictive Factors of Inpatient Rehabilitation Stay and Post-Discharge Burden of Care After Joint Replacement for Hip and Knee Osteoarthritis: A Retrospective Study on 1678 Patients

The global demand for end-stage hip and knee osteoarthritis surgical treatment is rising, as is the need of optimal postoperative rehabilitation. Patient stratification is key to provide rehabilitation professionals and policy makers with real-life data in support of early discharge planning and continuous care provision. The aim of this retrospective, observational study was to investigate which factors can predict the burden of care at discharge (BCD) and the inpatient rehabilitation length of stay (LOS) based on a set of demographic, societal, clinical and organizational data collected from a high-volume orthopedic hospital. We included 45.306 variables from 1678 patients. All variables were initially tested individually using a linear regression model for inpatient rehabilitation LOS and a logistic regression model for BCD. Variables that resulted significant (p < 0.05) were subsequently considered in a single, comprehensive linear regression model, or a single, logistic regression model, respectively. Age, living with a family, occupational status, baseline Barthel Index and duration of surgery were predictors of inpatient rehabilitation LOS and BCD. Sex, primary or secondary osteoarthritis, American Society of Anesthesiologists score, body mass index, transfusion, biological risk, type of anesthesia, day of surgery, numeric pain rating scale and baseline cognitive function at baseline were not. Including specific patient comorbidities, surgical access technique and chronic use of pharmacological therapy can improve the predictive power of the model.

The Referrer Matters. Musculoskeletal Surgical Conversion Rates: A Systematic Review With Meta-Analysis

Background

Efficient musculoskeletal care is important for health services and society. Surgical conversion rates are a common measure of efficiency, yet normal values and the impact of referrer type are unclear. This information could assist musculoskeletal care, service benchmarking and redesign.

Methods

A systematic review with meta-analysis was undertaken with PubMed, CINAHL and EMBASE databases searched from inception to 12th of October 2024, to identify studies from which musculoskeletal surgical conversion rates could be extracted. Data were categorised according to the professional group responsible for referral (all doctors, general practitioners, sports physicians, allied-health/physiotherapy-led screening services) and methodology used to define surgical conversion. Meta-analysis of pooled data was undertaken.

Results

Twenty-eight studies with a combined total of 5358 patients were included. Pooled data revealed surgical conversion rates of 23% for referrals from all types of doctors (0.23, 95% CI 0.18-0.27), 28% from general practitioners (0.28, 95% CI 0.12-0.52), 61% from allied health physiotherapy-led screening services (0.61, CI 0.50-0.70) and 70% from sports physicians at (0.70, CI 0.64-0.75). A variety of methodological factors impacted surgical conversion rate reporting and heterogeneity.

Conclusions

Musculoskeletal services seeking to improve efficiency through higher surgical conversion rates, should include sports physician and/or physiotherapy-led models of care for referral generation or management.

Undernutrition, Sarcopenia, Sarcopenic Obesity, and Sarcopenic Undernutrition: A Cross-sectional View on Patients Before Total Joint Arthroplasty

Diagnostic criteria of malnutrition phenotypes have been recently updated. Uncovering the prevalence of these conditions in patients undergoing hip replacement may be crucial in order to apply the most appropriate diagnostic-therapeutic paths to the right patient at the right time. Sixty patients aged between 60 and 85 undergoing elective hip replacement were recruited. Preoperative measures concerning eating behaviors, anthropometry, physical performance, laboratory parameters, and patient reported measures of pain and function were collected, used to make diagnosis, and explored whether they differed based on malnutrition categorization. Patients undernourished were 18.75%, sarcopenic 13.34%, sarcopenic obesity 4.26%, and 8.88% undernourished and sarcopenic. Well-nourished patients ate more cereals and meat, exhibited lower white blood cells but higher lymphocytes, and reported greater hip-related pain. One in three older patients undergoing elective hip replacement was malnourished. Eating behaviors and leucocytes were the discriminating factors between malnourished and well-nourished. It remains to be established whether malnutrition affects outcome after surgery.

Developing Physiotherapy in Primary Health Care: A First Snapshot from the Italian Metropolitan City of Milan

INTRODUCTION

Since the COVID-19 pandemic, the Italian National Health Service (NHS) has been undergoing a structural reform shifting focus from hospital-centered care to smaller, intermediate, or primary health facilities closer to the community (e.g., community hospitals and community houses). This reorganization should include rehabilitation and physiotherapy, but the actual spread of these services is still unclear.

OBJECTIVE

This study explored the number and characteristics of community-based physiotherapy services in the Metropolitan City of Milan (Italy).

METHODS

Between April and May 2024, we distributed a structured, anonymous online survey about community physiotherapy services and users to all Directors of the Health and Social Care Professions Departments (DAPSS) in the Metropolitan City of Milan. We used descriptive statistics to analyze the number of community houses offering physiotherapy services, the specific intervention areas, and access modalities.

RESULTS

Six out of seven DAPSS Directors completed the survey (87%). Thirty-seven community houses were reported in the area, with fourteen of these offering physiotherapy services. In most of them, physiotherapy was a primary reason for access following a general practitioner's prescription. Five out of six responders reported that rehabilitation needs were mainly assessed by specialists in Physical and Rehabilitation Medicine, with physiotherapists involved in the assessment process in two cases. Physiotherapists primarily handled the intervention phase, dealing mainly with orthopedic and neurological conditions. DAPSS Directors noted that additional physiotherapy initiatives focusing on prevention will be implemented.

CONCLUSIONS

Physiotherapy services are becoming available in the Metropolitan City of Milan. However, more efforts are needed to facilitate access and ensure tailored assessment and effective interventions, particularly in preventive care. Future investigations should help to better define the number and the characteristics of the patients who can most benefit from this type of care, the number of sessions they need, and with what types of intervention; it would be also necessary to better define the communication network in the area that allows doctors, health professionals, and patients to be informed about this possibility.

A Proposal for a Multidisciplinary Integrated Oral Health Network for Patients Undergoing Major Orthopaedic Surgery (IOHN-OS)

The passing of the years of life physiologically leads to the accumulation of changes in tissues in the oral cavity, influencing dentition, chewing and swallowing mechanisms, and the oral microbiota. Some diseases and medications can aggravate oral symptoms and negatively influence eating behaviours, increasing the likelihood of becoming malnourished. This could make older individuals more vulnerable to complications when undergoing major orthopaedic surgery. Hidden infection foci in the oral cavity are a recognised cause of post-operative periprosthetic joint infections. Dysfunctional oral problems might also compromise feeding after surgery when good nutrition represents a fundamental aspect of a proper recovery. To manage these shortcomings, in this article, the authors hypothesise a multidisciplinary path of care named the Integrated Oral Health Network applied to major Orthopaedic Surgery (IOHN-OS). This peri-operative initiative would include pre-operative oral health screening and risk management by a dental team, patient education programmes before and after surgery, and bedside gerodontology actions like oral care and meal and eating support for fragile individuals. The IOHN-OS has the potential to reshape the concept of suitability for major orthopaedic surgery and generate momentum for designing community-based surveillance programmes that can keep the mouths of older subjects healthy for a long time.

How Do Older Patients with End-Stage Osteoarthritis of the Hip Eat Prior to Hip Replacement? A Preliminary Snapshot That Highlights a Poor Diet

Diet quantity and quality in older adults is critical for the proper functioning of the musculoskeletal system. In view of hip surgery, old patients should consume 1.2-1.5 g of proteins and 27-30 kcal per kilo of body weight daily, and adhere to healthy eating habits. In this analytical study, we studied diet quantity and quality in relation to the clinical chemistry and functional status of 57 older adults undergoing elective hip replacement. Nine in ten patients did not meet suggested protein and energy intakes and only one in ten patients exhibited high adherence to the Mediterranean diet. Legume consumption adjusted for sex, age, body mass index, and health status successfully forecasted haemoglobin levels (p < 0.05), and patients regularly consuming olive oil reported minor hip disability compared to those using it less frequently (p < 0.05). Patients who reported daily ingestion of <1 serving of meat versus those consuming >1.5 servings had greater cumulative comorbidity (p < 0.05), with meat consumption independently predicting walking ability, mobility, and balance in the fully adjusted model (p < 0.01). In conclusion, our patients seem to eat poorly. There is room for improvement in pre-operative pathways to make older adults eat better, but there is a need to plan an interventional study to fully understand the cause-effect of a dietary pattern or specific food in enhancing recovery after surgery.