The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review

Prevalence and Clinical Impact of Sarcopenia in Patients Undergoing Total Joint Arthroplasty: A Systematic Review and a Meta-Analysis

BACKGROUND

Sarcopenia is a progressive loss of skeletal muscle mass and function. It is associated with adverse outcomes after several orthopaedic procedures. However, its role in total joint arthroplasty (TJA) is not fully explored. Therefore, we wanted to conduct a systematic review and meta-analysis to answer the following questions: (1) What is the prevalence of sarcopenia in patients undergoing TJA?; (2) What factors are associated with the prevalence of sarcopenia in patients undergoing TJA?; What is the impact of sarcopenia on medical outcomes following TJA?; and (4) What is the impact of sarcopenia on surgical outcomes following TJA?

METHODS

Electronic databases PubMed, Scopus, Cochrane, and Google Scholar were searched. The data were pooled using the random-effects model and graphically represented by a forest plot. We included a total of 13 studies, evaluating 399,097 patients.

RESULTS

The pooled prevalence of sarcopenia was 20.1% (95% confidence interval [CI] 13.6 to 28.8%; P < .00001; I2 = 94.7%) in total knee arthroplasty (TKA) and 5.2% (95% CI 0.1 to 69.7%; P = .128; I2 = 99.6%) in total hip arthroplasty (THA). Meta-regression found no links between age, sex, body mass index, diabetes, obesity, arthroplasty type, and sarcopenia prevalence in TJA. Sarcopenia increased risk of blood transfusion (odds ratio [OR] 4.68 [95% CI 3.51 to 6.25]; P < .00001), pneumonia (OR 1.94 [95% CI 1.14 to 3.30]; P = .01), urinary tract infection (UTI) (OR 1.64 [95% CI 1.31 to 2.05]; P < .001), prosthetic fracture (OR 2.12 [95% CI 1.51 to 2.98]; P < .0001), prosthetic dislocation (OR 1.99 [95% CI 1.62 to 2.44]; P < .00001), and mechanical loosening (OR 1.78 [95% CI 1.43 to 2.22]; P < .00001) in TKA. Sarcopenic patients were at an increased risk of UTI (OR 1.79 [95% CI 1.32 to 2.43]; P = .0002) and prosthetic loosening (OR 1.97 [95% CI 1.10 to 3.53]; P = .02) post-THA.

CONCLUSIONS

Baseline sarcopenia was prevalent in patients undergoing TJA. It was associated with an increased risk of UTI and prosthetic loosening following TKA and THA. Increased risk of blood transfusion, pneumonia, prosthetic fractures, and mechanical loosening following TKA.

Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study

BACKGROUND

COVID-19 has had a detrimental impact on access to hip and knee arthroplasty surgery. We set out to examine whether this had a subsequent impact on preoperative opioid prescribing rates for those awaiting surgery.

METHODS

Data regarding patient demographics and opioid utilisation were collected from the electronic health records of included patients at a large university teaching hospital. Patients on the outpatient waiting list for primary hip and knee arthroplasty as of September 2020 (COVID-19 group) were compared with historical controls (Controls) who had previously undergone surgery. A sample size calculation indicated 452 patients were required to detect a 15% difference in opioid prescription rates between groups.

RESULTS

A total of 548 patients (58.2% female) were included, 260 in the COVID-19 group and 288 in the Controls. Baseline demographics were similar between the groups. For those with data available, the proportion of patients on any opioid at follow-up in the COVID-19 group was significantly higher: 55.0% (143/260) compared with 41.2% (112/272) in the Controls (p=0.002). This remained significant when adjusted for confounding (age, gender, Scottish Index of Multiple Deprivation, procedure and wait time). The proportion of patients on a strong opioid was similar (4.2% (11/260) vs 4.8% (13/272)) for COVID-19 and Controls, respectively. The median waiting time from referral to follow-up was significantly longer in the COVID-19 group compared with the Controls (455 days vs 365 days; p<0.0001).

CONCLUSION

The work provides evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Prehabilitation in elective surgical interventions - what must the general and abdominal surgeon know

Objectives

For years, many efforts have been invested to prepare patients, in particular, those with reduced physical and psychic status, much better to provide and finally achieve better outocme if there is time available to provide several beneficial measures.

Methods

Therefore, the objective was to illustrate the concept and various single elements of a complex prehabilitation concept based on (i) selective references from the medical literature and (ii) own clinical experiences from clinical practice in general and abdominal surgery.

Results

Prehabiliation can be considered the solution of the efforts to improve preoperative status for patients in a disadvantageous status for almost all types of surgery and all other operative and/or interventional procedures. It is the targeted process to improve individual functionality and organ function before a planned (elective) surgical intervention; P. comprises basically nutritional, physical and psychological measures; P. focusses especially onto the elderly, frail and malnourished patients before a planned surgical intervention; the overall aim is to significantly improve final outcome characterized by shorter length of stay, lower complication rate and mortality as well as cost efficiency; P. is especially important in cancer surgery, in which the beneficial effects can be particularly implemented; P. programs and/or "Standard Operating Protocols" (SOP) may help to establish and materialize its single aspects and enhanced recovery after surgery (ERAS). There is still further potential to reliably establish and to utilize the options of prehabilitation measures as listed above.

Conclusions

Prehabiliation is an indispensable aspect in today's preparation for elective surgery, which needs to become obligatory part of the preparation measures to planned surgical interventions, which can further contribute to a better final outcome and ERAS as well as, in addtion, needs to be further developed and accomplished.

Interactive Combinations Between Gait Speed and Physical Function at Acute Phase Can Predict the Physical Activity at 2 Years After Total Knee Arthroplasty Using Classification and Regression Tree Analysis

OBJECTIVE

To clarify the interactive combinations of various clinical factors associated with physical activity (PA) at 2 years after total knee arthroplasty (TKA) using classification and regression tree (CART) analysis.

DESIGN

A retrospective cohort study.

SETTING

A single university hospital.

PARTICIPANTS

286 patients who underwent TKA (N=286).

MAIN OUTCOME MEASURES

PA was assessed preoperatively, 3 weeks, and 2 years after TKA. Physical functions, namely, 10 m walking test (10MWT), timed Up and Go test, 1-leg standing time, isometric knee extension and flexion strength, knee joint stability, knee pain, femora-tibial angle, and the passive knee extension and flexion angle, were measured before surgery as a baseline and 3 weeks after TKA as acute phase. CART analysis was conducted to clarify the interactive combinations that accurately predict the PA at 2 years after TKA.

RESULTS

The results of CART analysis indicated that gait speed (≥1.05 m/s) at the acute phase after TKA was the primal predictor for the postoperative PA at 2 years. The highest postoperative PA at 2 years was determined by gait speed (≥1.05 m/s) and PA (>74.5) at the acute phase. The PA at baseline and at acute phase, as well as the body mass index were also selected as predictors of postoperative PA at 2 years.

CONCLUSION

The present study suggested that acquiring gait speed (≥1.05 m/s) and PA (>74.5) in the postoperative acute phase is the predictive of a high PA at 2 years after TKA.

Action Observation and Motor Imagery administered the day before surgery enhance functional recovery in patients after total hip arthroplasty: A randomized controlled trial

OBJECTIVE

To investigate the effects of Action Observation and Motor Imagery administered the day before surgery on functional recovery in patients after total hip arthroplasty.

DESIGN

Randomised controlled trial.

SETTING

Humanitas Clinical and Research Center, Milan, Italy.

PARTICIPANTS

Eighty inpatients with end-stage hip osteoarthritis undergoing total hip arthroplasty.

INTERVENTIONS

All patients followed a standardized postoperative rehabilitation program. Experimental group (AO + MI) performed two 12-minute Action Observation and Motor Imagery sessions on the preoperative day, whereas control group underwent usual care consisting of education without any additional preoperative activity.

OUTCOME MEASURES

A blinded physiotherapist assessed participants for functional mobility (Timed Up and Go - TUG) (primary outcome), maximum walking speed (10-Meter Walk Test - 10MWT), pain (Numeric Pain Rating Scale - NPRS) and fear of movement (Tampa Scale of Kinesiophobia - TSK) the day before and at four days after surgery.

RESULTS

No between-group differences were found at baseline. Although TUG and 10MWT worsened in both groups (p < 0.001), better TUG was found for AO + MI group at four days (mean difference -5.8 s, 95% confidence interval from -11.3 to -0.3 s, p = 0.039). NPRS (p < 0.001) and TSK (p = 0.036 for AO + MI group, p = 0.003 for control group) improved after surgery without between-group differences.

CONCLUSIONS

Patients undergoing Action Observation and Motor Imagery on the day before surgery showed less functional decline than control group in the first days after total hip arthroplasty. This intervention may contribute to a safer discharge with higher functional abilities in patients hospitalized for total hip arthroplasty.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial

BACKGROUND

Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery.

METHODS

Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention.

DISCUSSION

Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.

Life After Total Hip Replacement: A Qualitative Study on Patient Experiences

The present study aimed to determine the life experiences of patients undergoing total hip replacement. This study was a qualitative study conducted using the content analysis method. Using purposive sampling, 10 patients with total hip replacement were selected and interviewed. Data were collected using semistructured interviews and were analyzed using the content analysis method. The mean age of the 10 patients was 59.33 ± 9.9 years. Six patients were female and four were male. Of these 10 participants, eight were married and had nuclear families; all participants were literate, and seven belonged to the middle-income group. Four main themes and 10 subthemes were identified. The themes included a painful process (severe pain and feeling of pain due to emotional exhaustion), fear (fear of feeling pain, fear of moving, and fear of recurrence), difficulty (self-care, sleep, and participation in social life), and positive thinking about life (feeling good and hope). The participants expressed mostly negative life experiences while also pointing out the positive life experiences. This study provides an in-depth understanding of the views of patients with total hip replacement on life experiences. These results can be used in planning and implementing health services for patients with total hip replacement.

The Long-Term Outcomes of Ablation With Vein of Marshall Ethanol Infusion vs. Ablation Alone in Patients With Atrial Fibrillation: A Meta-Analysis

Background

The long-term outcomes of ablation with vein of Marshall ethanol infusion (VOM-ABL) compared with ablation alone in patients with atrial fibrillation (AF) remains elusive. We aimed to explore whether VOM-ABL showed better long-term benefits and screen the potential determinants of outcome impact of VOM-ABL procedure.

Methods

PubMed, Cochrane Library, Web of Science, and Embase were searched up to 1st September 2021. Studies comparing the long-term (one-year or longer) outcomes between VOM-ABL and ablation alone were included. Subgroup analysis identified potential determinants for VOM-ABL procedure.

Results

Compared with ablation alone, VOM-ABL was associated with a significantly higher rate of long-term freedom from AF/AT (risk ratio [RR], 1.28; 95% confidence interval [CI], 1.12–1.47; p = 0.00) and successful mitral isthmus (MI) block (RR, 1.52; 95% CI, 1.16–1.99; p = 0.00), whereas, there was no significant difference in pericardial effusion, stroke/transient ischemic attack (TIA), and all-cause death. Subgroup analysis identified two significant treatment-covariate interactions: one was ablation strategy subgroup (pulmonary vein isolation plus linear and/or substrate ablation [PVI+]; RR, 1.41; 95% CI, 1.27–1.56 vs. PVI; RR, 1.05; 95% CI, 0.92–1.19, p = 0.00 for interaction) for freedom from AF/AT, while the other was VOM-ABL group sample size subgroup (≥ 100; RR, 1.98; 95% CI, 1.24–3.17 vs. <100; RR, 1.20; 95% CI, 1.10–1.30, p = 0.04 for interaction) for MI block.

Conclusions

This meta-analysis demonstrates that VOM-ABL has superior efficacy and comparable safety over ablation alone in AF patients with long-term follow-up. Moreover, PVI+ and VOM-ABL group sample size ≥ 100 may be associated with a great impact on freedom from AF/AT and MI block, respectively.

Introducing Virtual Prehabilitation to a UK Elective Total Hip Replacement service to improve patient outcomes: An overview of the literature and proposed implementation plan

Elective Total Hip Replacement (THR) surgery is one of the most common elective surgeries in the UK, costing the National Health Service (NHS) over £300,000,000 annually. A review of the literature identified preoperative rehabilitation, known as ‘prehabilitation’, improves patient outcomes and decreases Length Of hospital Stay (LOS). This approach follows NICE guidelines which recommend prehabilitation for all patients undergoing joint replacement surgery.

Challenges accessing prehabilitation classes at UK hospitals due to inadequate transport and COVID-19 restrictions present an opportunity to provide prehabilitation virtually. Physiotherapy services are increasingly utilising technology, in line with The NHS Long Term Plan to increase service accessibility.

A review of the literature has established virtual prehabilitation is effective, feasible, and preferable for patients. Quality Improvement methodology has been used to propose an implementation plan for a virtual prehabilitation service. Further research is required to create a standardised prehabilitation protocol, and to assess the long-term effects and sustainability of virtual prehabilitation.

Trimodal prehabilitation for older surgical patients: a systematic review and meta-analysis

OBJECTIVE

To determine the postoperative effectiveness of trimodal prehabilitation in older surgical patients.

METHODS

We searched Medline, PubMed, Embase, the Cochrane Library, Web of Science, and ClinicalTrials.gov for observational cohort studies and randomised controlled trials (RCTs) of older surgical patients who underwent trimodal prehabilitation. We performed a meta-analysis to estimate the pooled risk ratio (RR) for dichotomous data and weighted mean difference (MD) for continuous data. Primary outcomes were postoperative mortality and complications, and the secondary outcomes were the 6-min walk test (6MWT) at 4 and 8 weeks after surgery, readmission, and length of hospital stay (LOS). This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42020201347).

RESULTS

We included 10 studies (four RCTs and six cohort studies) comprising 1553 older surgical patients (trimodal prehabilitation group, n = 581; control group, n = 972). There were no significant differences in postoperative mortality (RR 1.32; 95% confidence interval [CI] 0.52-3.35) and postoperative complications (RR 0.91; 95% CI 0.76-1.09). Prehabilitation did not reduce readmission (RR 0.92; 95% CI 0.61-1.38) and LOS (MD 0.10; 95% CI  - 0.34-0.53). In a sub-analysis, trimodal prehabilitation did not significantly improve postoperative mortality, postoperative complications, readmission rates, or LOS when compared with standard care. However, trimodal prehabilitation significantly improved the 6MWT at 4 weeks after surgery (MD 37.49; 95% CI 5.81-69.18).

CONCLUSIONS

Our systematic review and meta-analysis demonstrated that trimodal prehabilitation did not reduce postoperative mortality and complications significantly but improved postoperative functional status in older surgical patients. Therefore, more high-quality trials are required.

Nutritional and Physical Prehabilitation in Elective Orthopedic Surgery: Rationale and Proposal for Implementation

In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient’s risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.

Effects of Preoperative Telerehabilitation on Muscle Strength, Range of Motion, and Functional Outcomes in Candidates for Total Knee Arthroplasty: A Single-Blind Randomized Controlled Trial

This study aims to investigate the effect of a preoperative telerehabilitation (PT) program on muscle strength, knee range of motion (ROM), and functional outcomes in candidates for total knee arthroplasty (TKA). Sixty patients (all women, mean age 70.53 ± 2.7 years) scheduled for bilateral TKA participated in this study. The PT and preoperative patient education (PE) groups participated in a 3-week intensive exercise program (30 min/session, 2 times/day, 5 days/week), whereas the control group received the usual care before TKA. Quadriceps muscle strength, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), ROM of knee flexion, pain, and time up-and-go (TUG) test time were evaluated at 4 weeks preoperatively, post-interventionally, and 6 weeks after TKA. Significant differences were found in the time-by-group interaction for 60°/s extension peak torque [F(4, 100) = 2.499, p = 0.047, η²_p = 0.91], 180°/s extension peak torque [F(4, 100) = 3.583, p = 0.009, η²_p = 0.125], ROM [F(4, 100) = 4.689, p = 0.002, η²_p = 0.158], TUG time [F(4, 100) = 7.252, p < 0.001, η²_p = 0.225], WOMAC pain [F(4, 100) = 9.113, p < 0.001, η²_p = 0.267], WOMAC functional outcome [F(4, 100) = 6.579, p < 0.001, η²_p = 0.208], and WOMAC total score [F(4, 100) = 10.410, p < 0.001, η²_p = 0.294]. The results of this study demonstrate the early benefits of a PT program in elderly female patients with end-stage osteoarthritis. The PT program improved muscle strength, ROM, and functional outcomes before TKA, which contributed to better functional recovery after TKA.

Therapeutic efficacy of zoledronic acid combined with calcitriol in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture

Zoledronic acid could improve the clinical outcome in elderly patients receiving total hip arthroplasty or hemiarthroplasty for osteoporotic femoral neck fracture in the 1-year prospective study.

INTRODUCTION

To validate the therapeutic efficacy of zoledronic acid (ZOL) in elderly patients with femoral neck fracture who received total hip arthroplasty (THA) or hemiarthroplasty (HA).

METHODS

Included in this study were 95 elderly patients with femoral neck fractures who received THA/HA between August 2015 and June 2018. They were randomized into a ZOL group and a control group. Patients in ZOL group received a yearly single dose of 5 mg ZOL intravenous injection plus 0.5 μg/day calcitriol and 1000 mg/day calcium carbonate 2 days before THA or HA. Patients in the control group were treated with the same dose of calcitriol and calcium carbonate only without ZOL. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Bone metabolism markers including the total extension of the peptide type I collagen amino end (P1NP) and beta collagen degradation product (β-CTX) were obtained by serum examination. The postoperative functional outcome was assessed using Harris Hip Score (HHS).

RESULTS

During the follow-up period, BMD in the ZOL group was improved and significantly higher than that in the control group at 6 and 12 months post-operation. Bone metabolism markers P1NP and β-CTX in ZOL group remained at a relatively low level as compared with that in the control group at 6 months after treatment. No significant difference in the mean HHS and the excellent/good rate of joint function was observed during the follow-up period between the two groups. The occurrence of adverse events in the ZOL group was significantly higher than that in the control group.

CONCLUSIONS

A single infusion of ZOL shows promise in improving BMD of the healthy side of the femoral neck, lumbar spine, and total hip and decreasing the level of bone markers, which may improve the clinical outcome of patients with osteoporotic femoral neck fractures receiving THA/HA.

Effect of prehabilitation in older adults undergoing total joint replacement: An Overview of Systematic Reviews

Purpose of Review

To review and discuss the findings of systematic reviews that synthesized the evidence on the effect of preoperative exercises (prehabilitation) on postoperative functional recovery in older adults undergoing total knee or hip joint replacement.

Recent Findings

Ten systematic reviews (8 meta-analyses) were included in this review. Findings from the systematic reviews indicated that prehabilitation decreases length of hospital stay but does not improve postoperative functional recovery in older adults undergoing joint replacement. Individual studies in the systematic reviews varied considerably in prehabilitation protocol, assessment timepoints, and outcome measures. Most importantly, systematic reviews did not assess the outcomes pre-post prehabilitation as this timepoint was not addressed in most individual studies. Therefore, it is not known whether the prehabilitation programs improved outcomes preoperatively.

Summary

There is a need to develop comprehensive prehabilitation protocols and systematically assess the preoperative and postoperative effectiveness of prehabilitation protocols on functional outcomes (i.e., self-reported and performance-based) in older adults undergoing total joint replacement.

The efficacy of perioperative gabapentin for the treatment of postoperative pain following total knee and hip arthroplasty: a meta-analysis

Background

Postoperative pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA) influence patients’ rehabilitation and life quality. Although gabapentin has been widely used for analgesia, its efficacy is still controversial in TKA and THA. This meta-analysis was performed to assess the efficacy and safety of gabapentin following TKA and THA.

Method

Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, MEDLINE, and ClinicalTrials.gov were comprehensively retrieved for randomized controlled trials from their inception to June 2019. A total of 7 studies, which compared the administration of gabapentin with that of placebo for the treatment of postoperative pain, were included in our meta-analysis. The meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Result

There was no difference in pain score at 24 (P = 0.87), 48 (P = 0.15), and 72 (P = 0.85) h associated with the use of gabapentin. Likewise, no difference in accumulative morphine consumption at 48 h following TKA or THA was found between gabapentin and placebo (DM = − 8.14, 95% CI − 18.55 to 2.28, P = 0.13). The incidence of opioid-related adverse effects, including nausea, pruritus, sedation, and dizziness, is no difference between gabapentin and placebo group. However, subgroup analysis indicated that gabapentin could reduce the incidence of pruritus after TKA (RR = 0.35, 95% CI 0.12 to 0.99, P = 0.05).

Conclusion

Based on our meta-analysis, gabapentin did not decrease postoperative pain, cumulative morphine consumption, and the incidence of adverse effects after TKA and THA. There was not enough evidence to support the administrations of gabapentin for postoperative pain after TKA and THA.

Return to Sport Activity in the Elderly Patients after Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis

In patients with knee osteoarthritis, when only medial or lateral compartment of the knee is involved, unicompartimental knee arthroplasty (UKA) is a reliable option for addressing the symptoms and restore function. The main aim of the present review is to systematically collect the available evidence concerning the return to sport activity in the elderly patients after UKA. An electronic search was carried out on the following databases; Pubmed-Medline, Cochrane central, and Scopus, searching for randomized controlled trials, prospective cohort studies, retrospective case-control studies, and case series. Data concerning the evaluation of the return to sport (RTS) and of functional outcomes in the elderly patients after UKA surgery. MINORS score was used to assess the risk of methodological biases. Odds ratios and raw proportions were used to report the pooled effect of UKA on the return to sport in comparative and non-comparative studies, respectively. Same level RTS in elderly patients was of 86% (pooled return proportion 0.86, 95%CI 0.78, 0.94), showing also better relative RTS and time to RTS of patients undergoing UKA, in comparison to those undergoing TKA. Sport-specific RTS showed that higher return rates were observed for low-impact sports, whereas high-impact sports prevented a full return to activities. UKA is a valid and reliable option for elderly patients to satisfactorily resume their sport practice, especially for low impact activities. The rate of return to sports following UKA is higher than TKA.

Prehabilitation May Help Mitigate an Increase in COVID-19 Peripandemic Surgical Morbidity and Mortality

As physicians specializing in rehabilitation medicine consider sequelae from the novel coronavirus pandemic that began in 2019, one issue that should be top of mind is the physiologic effect that large-scale social distancing had on the health of patients in general but, more specifically, on preoperative patients who had their surgeries delayed or will have newly scheduled procedures during the peripandemic period. Predictably, as the virus becomes less prevalent, there will be a tremendous motivation to move forward with scheduling operations from both patient care and institutional perspectives. However, one can anticipate a pandemic-related increase in surgical morbidity and mortality above prepandemic levels, particularly in older or medically frail patients evenif they did not have a novel coronavirus (i.e., COVID-19) infection. Therefore, now is the time to consider for patients awaiting surgery a wider adoption of prehabilitation—physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.

The role of an Orthopaedic Surgeon in the time of Covid-19 Pandemic-a German perspective

Covid-19 is a non-orthopaedic disease but is affecting the community of Orthopaedics as much as every part of our daily living. In this Editorial the different aspects of changes in our routine are described, based on the experience of this Editor in Germany.

I will try to give you a bit of background information first, as the situation is very much dependent on the specific phase of the pandemic and your place of work. The experience for an Orthopaedic Surgeon in New York or Madrid may differ from that of an Orthopaedic Surgeon in Singapore, or South Korea. As Europe is, at least at the moment, the most affected continent, it hopefully is an interesting topic for all of you.

The Covid-19 pandemic is affecting all aspects of our lives, therefore this editorial is divided into 4 sessions: Role as surgeon, as doctor, as teacher, and as family member.

Most countries have stopped elective surgeries and by that relegated Orthopaedic surgeons to a minimum of work. Keeping contact to patients with digital tools might be an option to achieve an organised restart after the end of the lock down period and to keep treating patients through that phase.

For many Orthopaedic surgeons, the principal task now is being part of an interdisciplinary team that is headed by colleagues from Internal Medicine or Anaesthesiology. Wards from the Orthopaedic department are reorganised as quarantine wards for Covid-19 patients.

Worldwide all conferences have been cancelled and nobody knows for how long this will continue. Education now has become fully digital, allowing to present and communicate without real limitations compared to conventional conferences. Some teaching options, such as hands-on workshops, fellowships, etc. are ceased and cannot be replaced by digital options.

Due to social distancing families are spending much more time together than before, while some family members, especially the people at risk (elders, ones with a fragile health) cannot be visited for a long time. Get togethers with friends as well as community meetings are completely suspended. For some of them, digital technology is the only option to minimize the problem of social distancing.

Overall, it has to be stated, that all parts of our lives as an Orthopaedic Surgeon are affected by the Covid-19 pandemic. As nobody knows how long these restrictions need to remain in place we have to accept them and work on improving this specific situation by following the rules. Hopefully, a vaccine will be developed in the near future, allowing us to return to a “normal” life. Nevertheless, it will never be like it was before.