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.

Definition of malnutrition from routinely-collected data for orthopedic surgery research: the global leadership initiative on malnutrition (GLIM) tool and others

The correct identification of malnourished patients in the context of hip, knee, or spine surgery research would enhance the quality of analytical studies investigating the prediction potential of preoperative nutritional disorders on postoperative recovery. However, accurate malnutrition screening and diagnostic assessment rely on parameters that were not routinely collected in routine practice until a few years ago. The authors of this article present substitute literature-based equations that can be built up using historical routinely collected data to classify patients that had been at risk of malnutrition or malnourished. For what concerns the risk screening, several methods are available to identify patients at risk of over- or undernutrition, encompassing the BWd (body weight difference from the ideal weight), GNRI (geriatric nutritional risk index), INA (instant nutritional assessment), LxA (combination of lymphocyte count and albumin), PMA (protein malnutrition with acute inflammation), PMAC (protein malnutrition with acute and chronic inflammation), IDM (iron deficit malnutrition), and VBD (vitamin B deficit malnutrition). Conversely, the GLIM (global leadership initiative on malnutrition) criteria can be used to assess malnutrition and diagnose subclasses of undernutrition. Rational use of these tools can facilitate the conduction of efficient prospective studies in the future, as well as bespoke retrospective cohort studies and database research.

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

Individuals with severe cartilage degeneration of the hip or knee or collapsed vertebrae that cause spine deformities can suffer from joint and neuropathic pain in the back, disuse of the affected limb, and restriction of movements. Surgical intervention is the most widespread and successful solution to date. There is a general belief that eating healthy and staying physically and mentally active might have a preventive role against musculoskeletal disease occurrence, while instead, we are more certain of the benefits deriving from a healthy diet and exercise therapy after major orthopaedic procedures. These aspects are in fact vital components in enhanced recovery after surgery programmes. However, they are applied in hospital settings, are often centre-dependent, and lack primary and tertiary preventive efficacy since end once the patient is discharged. There is the lack of initiatives at the territorial level that ensure a continuum in the patient's journey towards orthopaedic surgery, home transition, and a healthy and long-lasting life. The expert panel advocates the integration of an intermediate lifestyle clinic that promotes healthy eating, physical activity, and sleep hygiene. In this facility directed by professionals in enhancing recovery after surgery, patients can be referred after the surgical indication and before home discharge. Surgery is in fact a moment when individuals are more curious to do their best to heal and stay healthy, representing a timepoint and opportunity for educating patients on how lifestyle changes may optimise not only their surgical recovery but also long-term future health state.

Understanding the Patient Perspective When Designing Future Rehabilitation Interventions after Hip or Knee Replacement Surgery-A Patient and Public Involvement Exercise

Background and Objectives: Following discharge from hospital, there can be variability in the rehabilitation of patients who have undergone total hip or knee replacement surgery. We invited patients who had had hip or knee replacement surgery to take part in patient and public involvement sessions to help us understand their recovery needs and how rehabilitation services could potentially be improved to meet these needs better. Materials: Patients (n = 14) were invited to one of two patient advisory group sessions which took place in a university setting. Results: Feedback from patients highlighted the need for an inclusive, evidence-based intervention that would benefit patients experiencing all levels of pain, with differing motivations for recovery. Patients desired social support with others who have had similar surgery to reduce the burden of isolation during rehabilitation. Furthermore, patients valued the involvement of their partners and carers in their rehabilitation, to provide social support and guidance on recovery. Patients also expressed a need for consistent information and expert guidance on all aspects of their recovery. Conclusions: These findings can be used to guide the design of rehabilitation interventions following hip and knee replacement and ensure that patient perspectives inform future practice.

Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review

OBJECTIVE

Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes.

METHOD

A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'.

RESULTS

A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery.

CONCLUSION

The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

Healthy Eating for Elective Major Orthopedic Surgery: Quality, Quantity, and Timing

Improvements to enhanced recovery pathways in orthopedic surgery are reducing the time that patients spend in the hospital, giving an increasingly vital role to prehabilitation and/or rehabilitation after surgery. Nutritional support is an important tenant of perioperative medicine, with the aim to integrate the patient's diet with food components that are needed in greater amounts to support surgical fitness. Regardless of the time available between the time of contemplation of surgery and the day of admission, a patient who eats healthy is reasonably more suitable for surgery than a patient who does not meet the daily requirements for energy and nutrients. Moreover, a successful education for healthy food choices is one possible way to sustain the exercise therapy, improve recovery, and thus contribute to the patient's long-term health. The expected benefits presuppose that the patient follows a healthy diet, but it is unclear which advice is needed to improve dietary choices. We present the principles of healthy eating for patients undergoing major orthopedic surgery to lay the foundations of rational and valuable perioperative nutritional support programs. We discuss the concepts of nutritional use of food, requirements, portion size, dietary target, food variety, time variables of feeding, and the practical indications on what the last meal to be consumed six hours before the induction of anesthesia may be together with what is meant by clear fluids to be consumed until two hours before. Surgery may act as a vital "touch point" for some patients with the health service and is therefore a valuable opportunity for members of the perioperative team to promote optimal lifestyle choices, such as the notion and importance of healthy eating not just for surgery but also for long-term health benefit.

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance.

METHODS

CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033.

DISCUSSION

The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN19778222. Protocol v4.1, 24th October 2022.

A 1RM Strengthening and Exercise Programme for the Treatment of Knee Osteoarthritis: A Quality-Improvement Study

Background: The Kneefit programme is a 12-week strengthening and exercise programme, personalised using body-weight ratios, for people with knee osteoarthritis. Objectives and Design: This quality-improvement study was conducted to evaluate the effectiveness of the programme for managing symptomatic knee osteoarthritis. Methods: The Kneefit programme was delivered between 20 August 2013 and 7 January 2014 and included six weeks of supervised strengthening, balance, and cardiovascular exercise in a group at the local hospital, followed by six weeks of unsupervised exercise. Leg-press and knee-extension 1RM scores were assessed at baseline, six weeks, and twelve weeks. In addition, patient-reported outcome measures (Oxford Knee Score, EQ5D, Patient Specific Function Score (PSFS)) were assessed. Wilcoxon Signed Rank tests were used to evaluate the changes from week 1 to week 6 and week 12. Results: Thirty-six patients were included at baseline and at six weeks, and 31 patients completed their twelve-week assessment. Statistically significant improvements were found at 6 and 12 weeks for change for the Oxford Knee Score (median change: 4.0, IQR 4.0 to 9.0, p < 0.001 and 4.0, IQR 0 to 8.0, p < 0.001), EQ5D-5L (median change: 0.078, IQR 0.03 to 0.20, p < 0.001 and 0.071, IQR 0.02 to 0.25, p < 0.001) and the PSFS (median change: 1.3 IQR 0 to 2.6, p = 0.005 and 2.3 IQR -0.3 to 3.3, p = 0.016). In addition, significant improvements were found for 1RM leg-press and knee-extension scores on both the affected and unaffected legs. Conclusion: The Kneefit programme was successful at improving both functional and strength-related outcome measures in patients with knee osteoarthritis. Our findings suggest that tailoring strength exercises based on the 1RM strength-training principles is feasible in this population.

Patient-rated satisfaction and improvement following hip and knee replacements: Development of prediction models

RATIONALE

Effective preoperative assessments of determinants of health status and function may improve postoperative outcomes.

AIMS AND OBJECTIVES

We developed risk scores of preoperative patient factors and patient-reported outcome measures (PROMs) as predictors of patient-rated satisfaction and improvement following hip and knee replacements.

PATIENTS AND METHODS

Prospectively collected National Health Service and independent sector patient data (n = 30,457), including patients' self-reported demographics, comorbidities, PROMs (Oxford Hip/Knee score (OHS/OKS) and European Quality of Life (EQ5D index and health-scale), were analysed. Outcomes were defined as patient-reported satisfaction and improvement following surgery at 7-month follow-up. Univariable and multivariable-adjusted logistic regressions were undertaken to build prediction models; model discrimination was evaluated with the concordance index (c-index) and nomograms were developed to allow the estimation of probabilities.

RESULTS

Of the 14,651 subjects with responses for satisfaction following hip replacements 564 (3.8%) reported dissatisfaction, and 1433 (9.2%) of the 15,560 following knee replacement reported dissatisfaction. A total of 14,662 had responses for perceived improvement following hip replacement (lack of improvement in 391; 2.7%) and 15,588 following knee replacement (lack of improvements in 1092; 7.0%). Patients reporting poor outcomes had worse preoperative PROMs. Several factors, including age, gender, patient comorbidities and EQ5D, were included in the final prediction models: C-indices of these models were 0.613 and 0.618 for dissatisfaction and lack of improvement, respectively, for hip replacement and 0.614 and 0.598, respectively, for knee replacement.

CONCLUSIONS

Using easily accessible preoperative patient factors, including PROMs, we developed models which may help predict dissatisfaction and lack of improvement following hip and knee replacements and facilitate risk stratification and decision-making processes.

Using Gait Analysis to Evaluate Hip Replacement Outcomes—Its Current Use, and Proposed Future Importance: A Narrative Review

Total hip replacement (THR) is one of the most common elective orthopaedic operations. However, evidence suggests that despite postoperative pain improvements, aspects of longer-term physical performance, such as walking ability, do not reach the levels expected when compared to the general population. Walking is best assessed by using gait analysis. This review aims to explain the concept of gait analysis, its use to evaluate THR outcomes, and its proposed future importance when evaluating new technologies proposed to improve functional recovery in individuals undergoing THR surgery. Furthermore, this review discusses the advantages and challenges of gait analysis in THR patients and provides recommendations for future work.

The current and future role of nurses within enhanced recovery after surgery pathways

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research.

DISCUSSION

Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy.

CONCLUSION

Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.

Hip and Knee Arthroplasty

Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.

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.

Oral Hydration Before and After Hip Replacement: The Notion Behind Every Action

Introduction

Even though nearly 20 patients undergo hip replacement every hour just in Italy and the United Kingdom, it is unclear what are the most appropriate oral hydration practices that patients should follow before and after surgery. Improper administration can cause postoperative fluid disturbances or exacerbate pre-existing conditions, which are not an uncommon find in older subjects.

Significance

Considering that the number of hip operations is expected to increase in the next years as well as the age of patients, it is important to recall the notions behind water balance, especially in light of modern surgical and anesthetic practices. This technical perspective discusses the perioperative changes in the hydration status that occur during hip replacement and provides the concepts that help clinicians to better manage how much water the patient can drink.

Results

The points of view of the surgeon, the anesthetist, and the nurse are offered together with the description of mineral waters intended for human consumption. Before surgery, water should be always preferred over caffeinated, sugar-sweetened, and alcoholic beverages. The drinking requirements on the day of surgery should consider the water output from urine, feces, respiration, exudation, and bleeding along with the water input from metabolic production and intravenous administration of fluids and medications. Healthy eating habits provide water and should be promoted before and after surgery.

Conclusions

The judgment on which is the most appropriate approach to oral hydration practices must be the responsibility of the multidisciplinary perioperative team. Nevertheless, it is reasonable to argue that, in the presence of a patient with no relevant illness and who follows a healthy diet, it is more appropriate to stay closer to dehydration than liberalizing water intake both prior to surgery and in the early postoperative hours until the resumption of normal physiological functions.

Volumetric assessment of lower limb oedema using 3D laser scanning technique: a systematic review

Clinically, oedema is described as an abnormal build-up of interstitial fluid in the body that is enough to produce palpable swelling. Its assessment offers valuable information to clinicians as this can inform management interventions; and help monitor adherence to home therapy programmes and activity levels. The aim of this systematic review is to establish the utility of 3D scanning technologies in the assessment of lower limb oedema. A computer-based search was completed in October 2020. Four studies were identified which utilised a 3D scanner to measure lower limb oedema. A review of the studies found very little evidence to support the efficacy of 3D laser scanning technology, although they show that the use of the technology is feasible. Current methods of lower leg oedema measurement have issues with reliability, practicability and time taken. There is a need for future studies to validate new methods of oedema assessment using technologies such as 3D laser scanning.

A hospital-based mixed-methods observational study to evaluate a hip and knee replacement quality improvement project

Purpose

Health services continue to face economic and capacity challenges. Quality improvement (QI) methods that can improve clinical care processes are therefore needed. However, the successful use of current QI methods within hospital settings remains a challenge. There is considerable scope for improvement of elective clinical pathways, such as hip and knee replacement, and so the use and study of QI methods in such settings is warranted.

Design/methodology/approach

A model to manage variability was adapted for use as a QI method and deployed to improve a hip and knee replacement surgical pathway. A prospective observational study, with a mixed-methods sequential explanatory design (quantitative emphasised) that consisted of two distinct phases, was used to assess its effectiveness.

Findings

Following the use of the novel QI method and the subsequent changes to care processes, the length of hospital stay was reduced by 18%. However, the interventions to improve care process highlighted by the QI method were not fully implemented. The qualitative data revealed that staff thought the new QI method (the model to manage variability) was simple, effective, offered advantages over other QI methods and had highlighted the correct changes to make. However, they felt that contextual factors around leadership, staffing and organisational issues had prevented changes being implemented and a greater improvement being made.

Originality/value

The quality of QI reporting in surgery has previously been highlighted as poor and lacking in prospective and comprehensively reported mixed-methods evaluations. This study therefore not only describes and presents the results of using a novel QI method but also provides new insights in regard to important contextual factors that may influence the success of QI methods and efforts.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Importance

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations

Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions and Relevance

To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

Adherence to Neuromuscular Electrical Stimulation Interventions for Muscle Impairment in Hip and Knee Osteoarthritis: A Systematic Review

Background

Neuromuscular electrical stimulation (NMES) provides a promising approach to counteract muscle impairment in hip and knee osteoarthritis, and to expedite recovery from joint replacement surgery. Nonetheless, application into clinical orthopaedic practice remains limited, partly due to concerns regarding patient tolerance.

Objectives

This systematic review aimed to quantify levels of adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis and identify strategies to increase compliance.

Data Sources

Randomised controlled trials (RCTs) were identified in a web-based literature review, completed in December 2020. The databases sourced included the Cochrane Library, CINAHL Complete, Medline Complete and PubMed.

Eligibility Criteria

Studies were included if they were: (i) conducted in cohorts of adults with hip or knee osteoarthritis; (ii) a protocol of electrical muscle stimulation prescribed to treat muscle impairment; and (iii) reported intervention adherence or attrition rate. Data were extracted on adherence rate, reasons for non-adherence and potential strategies to increase adherence. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale.

Results

The search yielded 120 articles, of which 15 studies were considered eligible and included in the analysis (n = 922). All NMES treatment was applied to the quadriceps, with 1 study targeting the quadriceps and calves. The mean PEDRO score of the included studies was 6.80 out of a possible 10 (range 6-8). Mean adherence did not differ between groups receiving treatment with NMES (85% ± 12%) and control groups receiving voluntary exercise or education (84% ± 9%) (P = .97). Reasons for non-adherence or attrition included a dislike of the device, dizziness, pain and discomfort. Strategies to increase adherence included NMES education, a familiarisation period, supervision, setting thresholds based upon patient tolerance, monitoring pain levels during stimulation and using built-in adherence trackers.

Conclusions

This systematic review indicates that adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis in clinical trials does not differ to control groups receiving education or voluntary exercise, and hence should not be a barrier to application in clinical practice.

Strength and endurance deficits in adults with moderate-to-severe hip osteoarthritis, compared to healthy, older adults

PURPOSE

This study compares lower limb muscle strength and endurance in adults with hip osteoarthritis, to an age-matched control group.

METHODS

Thirteen adults with moderate-to-severe hip osteoarthritis (as graded by the Oxford Hip Score) and fifteen older adults participated. Maximal voluntary isometric contraction of the knee extensors, knee flexors and hip abductors and isotonic endurance of the knee extensors were measured using a dynamometer. Function was assessed using the 30-second chair stand test, the 40 m fast-paced walk test and a stair negotiation test. Data were compared between groups using t-tests.

RESULTS

Participants with hip osteoarthritis demonstrated weakness in the affected limb when compared to the control limb during knee flexion (34%, p = 0.004) and hip abduction (46%, p = 0.001). Weakness was also observed in the contralateral knee flexors (31%, p = 0.01). When compared to the control limb, the knee extensors of the hip osteoarthritis group were exhausted prematurely in the affected (70%, p = 0.001) and contralateral limb (62%, p = 0.005). The hip osteoarthritis group took twice as long to stair climb (p = 0.002), walked 40% slower, (p < 0.001), and had a 35% lower sit-stand performance (p < 0.001).

CONCLUSIONS

Moderate-to-severe hip osteoarthritis may be characterised by bilateral deficits in lower-limb maximal strength, markedly lower knee extensor endurance and impaired functional performance.Implications for rehabilitationIn addition to bilateral deficits in maximal strength of the hip and knee muscles, moderate-to-severe hip osteoarthritis may be characterised by markedly lower muscular endurance of the knee extensors and impaired functional performance.The endurance capacity of the knee extensors can play an important role in daily function, and thus it is important to consider endurance training principles when prescribing exercise for this patient group.Research studies evaluating exercise programmes underpinned by endurance training principles are required to understand the benefits to patients with hip osteoarthritis, and to inform specific exercise prescription in clinical practice.

The quality of intervention reporting in trials of therapeutic exercise for hip osteoarthritis: a secondary analysis of a systematic review

BACKGROUND

Therapeutic exercise is recommended as a core treatment for hip osteoarthritis (HOA). Whilst it is widely accepted that exercise can improve pain and disability, optimal type and dose of exercise are yet to be agreed upon. This may, in part, be attributed to the wide variation and inadequate reporting of interventions within the literature. This study evaluates the quality of intervention reporting among trials of therapeutic exercise in HOA.

METHODS

Randomised controlled trials (RCTs) were sourced in a systematic review, completed in August 2020. Two raters independently used the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT) to evaluate intervention reporting. Correlations between quality assessment scores and CERT and TIDieR scores evaluated the relationship between internal validity and external applicability. The year of publication was compared to the quality of reporting scores.

RESULTS

Fourteen RCTs were included in the analysis. On average, studies were awarded 9.43 ± 1.95 out of 12 points for the TIDieR checklist (range 4-12) and 13.57 ± 4.01 out of 19 points for the CERT (range 5-19). Pearson's correlation coefficient suggested that the quality of reporting had improved over time and that there was a fair, positive relationship between internal validity and external applicability.

DISCUSSION

Whilst the quality of intervention reporting is improving, many RCTs of therapeutic exercise in HOA lack the detail necessary to allow accurate evaluation and replication. Researchers are encouraged to utilise the standardised reporting guidelines to increase the translation of effective interventions into clinical practice.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

The current status of daycase hip and knee arthroplasty within the English National Health Service: a retrospective analysis of hospital episode statistics data

INTRODUCTION

A high volume of total hip, total knee and unicompartmental knee arthroplasty procedures, an ageing population and continuing financial pressures within the English NHS mean that strategies to reduce length of hospital stay are attractive. Enhanced recovery after surgery protocols are one such intervention, and have advanced so that daycase arthroplasty is now possible. This study examines the current rate of daycase arthroplasty within the English NHS.

MATERIALS AND METHODS

Hospital episode statistics data from all English NHS providers of arthroplasty procedures were analysed. Activity, daycase rate, length of stay and readmission rates were recorded. All total hip, knee and unicompartmental knee operations undertaken within the time period 1 July 2018 to 30 June 2019 were examined.

RESULTS

Length of stay was analysed for 162,966 patients; 74,665 (46%) were total hip arthroplasty, 79,252 (49%) were total knee arthroplasty and 9,049 were unicompartmental knee arthroplasty (5%). Mean length of stay was 4.08 days for total hip, 4.11 days for total knee and 2.64 days for unicompartmental knee arthroplasties. Daycase rate for total hip arthroplasty was 0.55%, 0.52% for total knee arthroplasty and 5.44% for unicompartmental knee arthroplasty. The percentage of patients staying in hospital for longer than four days (a length of stay of five days or more) was 18.61% of total hip arthroplasty spells, 20.54% of total knee arthroplasty spells and 5.48% of unicompartmental knee arthroplasty spells.

DISCUSSION

This large observational study of unselected patients undergoing hip and knee arthroplasty demonstrates that the national daycase rate for arthroplasty across providers in the NHS is low. Mean length of stay remains higher than selected international comparators.

Effect of neuromuscular electrical stimulation on the recovery of people with COVID-19 admitted to the intensive care unit: A narrative review

The rehabilitation of patients with COVID-19 after prolonged treatment in the intensive care unit is often complex and challenging. Patients may develop a myriad of long-term multi-organ impairments, affecting the respiratory, cardiac, neurological, digestive and musculoskeletal systems. Skeletal muscle dysfunction of respiratory and limb muscles, commonly referred to as intensive care unit acquired weakness, occurs in approximately 40% of all patients admitted to intensive care. The impact on mobility and return to activities of daily living is severe. Furthermore, many patients experience ongoing symptoms of fatigue, weakness and shortness of breath, in what is being described as “long COVID”. Neuromuscular electrical stimulation is a technique in which small electrical impulses are applied to skeletal muscle to cause contractions when voluntary muscle contraction is difficult or impossible. Neuromuscular electrical stimulation can prevent muscle atrophy, improve muscle strength and function, maintain blood flow and reduce oedema. This review examines the evidence, current guidelines, and proposed benefits of using neuromuscular electrical stimulation with patients admitted to the intensive care unit. Practical recommendations for using electrical muscle stimulation in patients with COVID-19 are provided, and suggestions for further research are proposed.

Evidence suggests NMES may play a role in the weaning of patients from ventilators and can be continued in the post-acute and longer-term phases of recovery. As such, NMES may be a suitable treatment modality to implement within rehabilitation pathways for COVID-19, with consideration of the practical and safety issues highlighted within this review.

Enhanced Recovery after Surgery (ERAS) for Hip and Knee Replacement-Why and How It Should Be Implemented Following the COVID-19 Pandemic

The COVID-19 pandemic has led to a reduction in hip and knee replacement surgery across healthcare systems. When regular operating returns, there will be a large volume of patients and an emphasis on a short hospital stay. Patients will be keen to return home, and capacity will need to maximised. Strategies to reduce the associated risks of surgery and to accelerate recovery will be needed, and so Enhanced Recovery after Surgery (ERAS) should be promoted as the model of care. ERAS protocols are proven to reduce hospital stay safely; however, ERAS pathways may require adaption to ensure both patient and staff safety. The risk of exposure to possible sources of COVID-19 should be limited, and so hospital visits should be minimised. The use of technology such as smartphone apps to provide pre-operative education, wearable activity trackers to assist with rehabilitation, and the use of telemedicine to complete outpatient appointments may be utilised. Also, units should be reminded that ERAS protocols are multi-modal, and every component is vital to minimise the surgical stress response. The focus should be on providing better and not just faster care. Units should learn from the past in order to expedite the implementation of or adaption of existing ERAS protocols. Strong leadership will be required, along with a supportive organisational culture, an inter-professional approach, and a recognised QI method should be used to contextualize improvement efforts.

Lower limb kinematic, kinetic and spatial-temporal gait data for healthy adults using a self-paced treadmill

Through gait analysis, gait phases can be identified, the kinematic and kinetic parameters of human gait events can be determined, and quantitative evaluation can be undertaken. This data article is the first to report a comprehensive data set on a large cohort of healthy participants. Individual strides were determined from vertical force data and all kinematics and kinetic data separated into strides. Local minima and maxima were determined respectively for each anatomical region and the mean calculated for twenty of the 25 strides. When twenty strides were not available the mean of ten strides was used. Stride data were time normalised so one stride was represented by 100%. In addition to the local maxima and minima, the kinematic- and kinetic-time curves were explored and used to determine the mean kinematic-time and kinetic-time curves across all trials and participants (∼1800 gait cycles) to provide mean±sd kinematic- and kinetic-time curves for each of the anatomical regions.

Lab-based feasibility and acceptability of neuromuscular electrical stimulation in hip osteoarthritis rehabilitation

INTRODUCTION

Neuromuscular electrical stimulation (NMES) could provide an alternative or adjunct treatment modality to induce muscle hypertrophy in the hip osteoarthritis population. This preliminary study evaluates the feasibility and acceptability of NMES to evoke involuntary muscle contractions in adults with advanced hip osteoarthritis.

METHODS

Thirteen adults with moderate-to-severe hip osteoarthritis and fifteen healthy, older adults were invited to a lab-based testing session. NMES was applied unilaterally to the knee extensors and hip abductors for one continuous, five-minute testing session. Data were collected on device acceptability, tolerability and muscle contractile force, and compared between groups.

RESULTS

Electrical stimulation of the knee extensors elicited a visible muscular contraction in 11 participants (85%) with hip osteoarthritis and 15 controls (100%) at an intensity acceptable to the participant. Electrical stimulation of the hip abductors elicited a muscular contraction in eight participants (62%) with osteoarthritis, and ten controls (67%). Muscle contractile force, pain, discomfort and acceptability did not differ between groups, however NMES of the knee extensors was favoured across all measures of assessment when compared to the hip abductors.

CONCLUSIONS

Electrical stimulation of the knee extensors may be a feasible and acceptable treatment modality to address muscle atrophy in adults with advanced hip osteoarthritis.

Patient Information Leaflets for Lumbar Spine Surgery: A Missed Opportunity

BACKGROUND

High-quality patient information is recommended to help reduce procedure-related anxiety and encourage patients to become active participants in their recovery. The objective of this study was to analyze the quality of patient information leaflets (PILs) given to National Health Service (NHS) patients ahead of lumbar spine surgery.

METHODS

The DISCERN tool was used to evaluate the quality of PILs, sourced from NHS websites.

RESULTS

Thirty-two PILs on lumbar surgery were included. Two (6%) leaflets were considered poor, 13 (41%) were marked as fair, 14 (44%) were of good quality, and 3 (9%) were scored as excellent. The total mean score was 55 (30-74), which corresponds to good quality. The lowest scoring questions were sources of information (Q4), balanced/unbiased content (Q6), and explanation of no treatment (Q12).

CONCLUSIONS

There is considerable variation in the quality of PILs provided ahead of lumbar spine surgery. The scope for improvement is clear, and as the move toward patient-centered, evidence-based care continues, it is important that hospital resources provide recommendations based upon evidence of clinical effectiveness.

The Quality Improvement Challenge-How Nurses and Allied Health Professionals Can Solve the Knowing-Doing Gap in Enhanced Recovery after Surgery (ERAS)

The English National Health Service (NHS), and all health services around the world, will continue to face economic and capacity challenges. Quality improvement (QI) interventions, such as Enhanced Recovery after Surgery (ERAS), that are proven to improve patient care and deliver operational benefits are therefore needed. However, widespread implementation remains a challenge. Implementation of ERAS within the NHS over the last 10 years is reviewed, with a focus on total hip arthroplasty (THA) and total knee arthroplasty (TKA). Difficulties with implementation are highlighted, and a recommendation for the future is presented. This perspective is novel in the ERAS literature, and centres around increasing the understanding of perioperative care teams on the need for utilising a recognised QI method (e.g., plan–do–study–act cycles, Lean, and Six Sigma) to implement ERAS protocols (which are a QI intervention) successfully. The importance of differentiating between a QI method and a QI intervention has value across all other ERAS surgical procedures.

Reliability of gait parameters in male and female healthy adults during self-paced treadmill-based walking

Background/aims

The purpose of this study was to examine the intra-rater reliability of the Gait Real-time Analysis Interactive Laboratory system during self-paced mode, in repeated gait analysis of healthy individuals.

Methods

A total of 10 healthy men (age: 35.4 ± 13.3 years; body mass index: 25.2 ± 4.3) and 10 healthy women (age: 41.1 ± 16.4 years; body mass index: 24.5 ± 2.6) were split into two groups according to sex. They walked on a split-belt, self-paced treadmill. Each participant completed two gait assessments separated by an average of 7 ± 3 days. Key gait kinematic, kinetic and spatial-temporal parameters were analysed. The interclass correlation coefficient, standard error of measurement and minimum detectable change were calculated to evaluate the reliability of these gait parameters.

Results

There was a high repeatability of spatial temporal and excellent repeatability of kinematic and kinetic parameters in both groups.

Conclusions

The findings suggest that the Gait Real-time Analysis Interactive Laboratory system in self-paced mode is a good instrument to evaluate gait parameters for women as well as men.

A cycling and education intervention for the treatment of hip osteoarthritis: A quality improvement replication programme

Objectives:

The Cycling against Hip Pain programme is a 6-week exercise and education treatment pathway for people with hip osteoarthritis. Preliminary results of the Cycling against Hip Pain programme found significant improvements in clinical and patient-reported outcome measures for patients referred from primary care. This article evaluates the effectiveness of the changes made to the pathway in a quality improvement replication programme.

Methods:

The replicated Cycling against Hip Pain programme was delivered between February 2018 and September 2019 in a region of England with a high percentage of adults aged over 65 years. All participants were referred from the orthopaedic outpatient department of the funding hospital (secondary care). The programme was delivered at a local leisure centre and combined 30 min of education on osteoarthritis with 30 min of progressive static cycling, once a week for 6 weeks.

Results:

The participants on the replicated Cycling against Hip Pain programme did not differ from the original cohort in terms of age or pre-programme weight, however, presented with worse hip symptoms at baseline. Consistent with the findings from the original cohort, participants demonstrated significant improvements to their Oxford Hip Score, 30-s chair stand performance, Timed Up and Go score, Hip Osteoarthritis Outcome Score function and pain, EQ5D health rating, EQ5D-5L score and pain at rest and on weight bearing. In addition, participants reported an increase in knowledge, confidence and motivation to exercise.

Conclusion:

A 6-week cycling and education intervention for the treatment of hip osteoarthritis provided benefits to function, pain and quality of life for patients referred from secondary care. These results are consistent with findings from patients who were referred from primary care and further support the potential of the pathway in the conservative management of hip osteoarthritis.

A Single-Centre Feasibility Randomised Controlled Trial Comparing the Incidence of Asymptomatic and Symptomatic Deep Vein Thrombosis Between a Neuromuscular Electrostimulation Device and Thromboembolism Deterrent Stockings in Post-Operative Patients Recovering From Elective Total Hip Replacement Surgery

BACKGROUND

Total hip replacement is recognised as a major risk factor for deep vein thrombosis (DVT). The aim of this study was to investigate the feasibility of using a novel neuromuscular electrical stimulation device (NMES) for DVT prevention in patients recovering from elective hip replacement surgery.

METHODS

Twenty-eight patients undergoing total hip replacement were randomised to receive postoperative treatment with either the NMES device or compression stockings continually from post-surgery until discharge (day 4). The primary outcome measure was the presence of symptomatic or asymptomatic DVT at 48 hours post-surgery and on the day of discharge from hip replacement surgery, as assessed by Duplex ultrasound. Secondary outcomes included hemodynamic responses to the devices, lower limb oedema, sit-to-stand and timed-up-and-go (TUG) scores, and hip range of motion.

RESULTS

In the compression stockings group, two cases of asymptomatic DVT were identified by Duplex ultrasound at 48 hours post-surgery. No cases were found in the NMES group. Patients in the NMES group demonstrated a general trend of a decrease in leg volume from post-surgery to discharge, whereas leg volume largely remained static for the compression stockings group. In addition, positive hemodynamic effects were found in favour of the NMES group in the non-operated leg. The change in TUG scores also favoured the NMES group (NMES: 150 ± 152%, compression stockings: 363 ± 257% (p=0.03)), whereas no differences in sit-to-stand scores or hip range of motion were observed.

CONCLUSIONS

This study supports the feasibility of NMES as an alternative mechanical prophylaxis worn in the postoperative phase until discharge and provides important findings for clinicians considering novel mechanical prophylaxis options.

Lower Limb Biomechanical Analysis of Healthy Participants

Biomechanical analysis techniques are useful in the study of human movement. The aim of this study was to introduce a technique for the lower limb biomechanical assessment in healthy participants using commercially available systems. Separate protocols were introduced for the gait analysis and muscle strength testing systems. To ensure maximum accuracy for gait assessment, attention should be given to the marker placements and self-paced treadmill acclimatization time. Similarly, participant positioning, a practice trial, and verbal encouragement are three critical stages in muscle strength testing. The current evidence suggests that the methodology outlined in this article may be effective for the assessment of lower limb biomechanics.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Validation of the Anterior Cruciate Ligament (ACL) Module of the VirtaMed Virtual Reality Arthroscopy Trainer

OBJECTIVE

To assess the newly developed anterior cruciate ligament (ACL) module of a VR arthroscopy trainer for content, construct and face validity.

DESIGN

Participants were divided into expert and novice groups based on their experience with ACL arthroscopy. Participants were given a standardized introduction, shown a video on how to use the simulator, and performed a 5-minute partial meniscectomy task, to familiarise them with the equipment. Participants then undertook an ACL reconstruction task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, ACL Reconstruction, Safety, Economy, Detailed Visualization and Total Score. A 7-point Likert scale questionnaire was used to assess the face and content validity of the simulator.

PARTICIPANTS

Twenty one participants from a hospital orthopaedic department were recruited. Five were classified as expert, 16 as novice.

RESULTS

An independent Mann-Whitney U test showed no significant differences between experts and novices for any of the domains. Questionnaire responses regarding hand-eye coordination, camera navigation training, diagnostic training, tunnel preparation and overall training capacity were scored as either 'good' or 'excellent' by more than 70% of the participants. All responses regarding the 'graft insertion task' scored low.

CONCLUSION

The current iteration of the VR knee ArthroS™ simulator (VirtaMed AG, Zurich, Switzerland) is promising, but requires further development of the ACL procedure, in particular the graft insertion task, before it can be considered as part of training curricula.

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review

Early mobilisation is a cornerstone of Enhanced Recovery after Surgery (ERAS) and is encouraged following spinal procedures. However, evidence of its implementation is limited and there are no formal guidelines on optimal prescription. This narrative review aimed to evaluate the evidence for the effect of early mobilisation following elective spinal surgery on length of stay, postoperative complications, performance-based function and patient-reported outcomes. Four trials (five articles) that compared a specific protocol of early in-hospital mobilisation to no structured mobilisation or bed rest were selected for inclusion. Nine studies that investigated the implementation of a multimodal intervention that was inclusive of an early mobilisation protocol were also included. Results suggest that goal-directed early mobilisation, delivered using an evidence-based algorithm with a clear, procedure-specific inclusion and exclusion criteria, may reduce length of stay and complication rate. In addition, there is evidence to suggest improved performance-based and patient-reported outcomes when compared to bed rest following elective spinal surgery. Whilst this review reveals a lack of evidence to determine the exact details of which early mobilisation protocols are most effective, mobilisation on the day of surgery and ambulation from the first postoperative day is possible and should be the goal. Future work should aim to establish consensus-based, best practice guidelines on the optimal type and timing of mobilisation, and how this should be modified for different spinal procedures.

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

The effects of knee joint angle on neuromuscular activity during electrostimulation in healthy older adults

Introduction

Electrostimulation devices stimulate the common peroneal nerve, producing a calf muscle-pump action to promote venous circulation. Whether knee joint angle influences calf neuromuscular activity remains unclear. Our aim was to determine the effects of knee joint angle on lower limb neuromuscular activity during electrostimulation.

Methods

Fifteen healthy, older adults underwent 60 min of electrostimulation, with the knee joint at three different angles (0°, 45° or 90° flexion; random order; 20 min each). Outcome variables included electromyography of the peroneus longus, tibialis anterior and gastrocnemius medialis and lateralis and discomfort.

Results

Knee angle did not influence tibialis anterior and peroneus longus neuromuscular activity during electrostimulation. Neuromuscular activity was greater in the gastrocnemius medialis (p = 0.002) and lateralis (p = 0.002) at 90°, than 0° knee angle. Electrostimulation intensity was positively related to neuromuscular activity for each muscle, with a knee angle effect for the gastrocnemius medialis (p = 0.05).

Conclusion

Results suggest that during electrostimulation, knee joint angle influenced gastrocnemii neuromuscular activity; increased gastrocnemius medialis activity across all intensities (at 90°), when compared to 0° and 45° flexion; and did not influence peroneus longus and tibialis anterior activity. Greater electrostimulation-evoked gastrocnemii activity has implications for producing a more forceful calf muscle-pump action, potentially further improving venous flow.

Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery?

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been successfully adopted across a range of procedures. This study explores whether there is scope to improve length of stay (LOS) for total ankle replacement surgery (TAR) in the UK by implementing ERAS pathways.

METHODS

Hospital Episode Statistics (HES) data (April 2015/March 2016) on LOS for TAR were analysed. A literature search was then carried out to examine whether there were any publications on outpatient TAR and/or the use of ERAS protocols.

RESULTS

Mean observed LOS was 3.3days (range 0-17.3) days. Case mix-adjusted expected LOS range was 2.0-5.7 days. It is likely that the wide observed LOS range is due to differences in local processes and pathways. Two papers were found by the literature search.

CONCLUSIONS

TAR should aim to be outpatient surgery as the literature, and data demonstrating scope for improvement in LOS, suggest this should be possible.

Effectiveness of neuromuscular electrical stimulation for reducing oedema: A systematic review

OBJECTIVE

This systematic review aimed to assess the clinical impact of neuromuscular electrical stimulation as a treatment modality for patients with oedema.

DATA SOURCES AND STUDY SELECTION

PubMed was searched up to July 2018 for randomized and non-randomized clinical trials comparing neuromuscular electrical stimulation vs no stimulation following the formation of oedema. A modified Downs and Black checklist was used to evaluate the quality of the evidence.

DATA SYNTHESIS

Initial searches yielded 150 results. Removal of duplicates reduced this number to 97 results. Seventy-five studies were excluded following a review of titles and abstracts. Full-text screening eliminated 15 studies. A final total of 7 studies met the inclusion criteria. Six studies supported the use of neuromuscular electrical stimulation for oedema reduction, and one study did not find an effect, but reported inter-group variance.

CONCLUSION

The results of this systematic review support the use of neuromuscular electrical stimulation for ameliorating the abnormal accumulation of interstitial fluid, which is clinically shown as oedema. Neuromuscular electrical stimulation is effective in a number of rehabilitation settings and patient groups, for treatment of both upper and lower limb oedema. However, further trials are needed to reinforce these findings.

Does Neuromuscular Electrical Stimulation Improve Recovery Following Acute Ankle Sprain? A Pilot Randomised Controlled Trial

Aim:

Following soft tissue ankle injury, patients are often referred for out-patient physiotherapy and present symptoms including pain, reduced range of movement and function, and oedema. In this study, we assess the use of a neuromuscular electrical stimulation (NMES) device as an adjunctive therapy to reduce oedema in patients recovering from grade I and II ankle sprains.

Methods:

This was a single-centre, pilot randomised controlled study, recruiting patients referred to physiotherapy following an ankle sprain. Participants presenting with oedema were randomised to one of two treatment groups: (1) the current standard of care and (2) the current standard of care plus NMES use. Participants were identified in an emergency department and referred to a physiotherapy department for treatment 1 to 5 days following the injury and returned to clinic 7 days later.

Results:

Twenty-two participants completed the study and had full data sets for analysis (11 in each group). Mean volumetric displacement was reduced in the intervention group in comparison to the standard care group (P = .011); however, there were no between-group differences in figure of eight measurements, function or pain scores. The device was well tolerated, with no device-related adverse events recorded.

Conclusions:

In this pilot, randomised controlled trial, NMES was well tolerated by patients following ankle sprain and demonstrated statistically significant improvements in oedema reduction as measured by fluid displacement. No other changes were observed. Further work will need to confirm the clinical significance and effect on longer term recovery post-ankle sprain.

Validation of the Hip Arthroscopy Module of the VirtaMed Virtual Reality Arthroscopy Trainer

OBJECTIVE

To assess the face, content and construct validity of a virtual reality hip arthroscopy simulator (Arthros™, VirtaMed AG, Schlieren, Switzerland).

DESIGN

Participants were divided into Expert and Novice groups depending on whether or not they had assisted with or performed more than 50 hip arthroscopy procedures. Participants were given a standardized introduction and shown a video on how to use the simulator. To familiarise themselves with the equipment, they were then given a 5-minute diagnostic task to complete. Participants then performed a therapeutic task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, Safety, Economy, Detailed Visualization and Overall Score. Participants completed a 7-point Likert-scale questionnaire to assess the face and content validity of the simulator.

SETTING

University lab or exhibition stand at an orthopaedic conference.

PARTICIPANTS

Clinicians from a hospital orthopaedic department and attendees at a UK orthopaedic conference with varying levels of experience in hip arthroscopy surgery.

RESULTS

Twenty-two participants were recruited. Six were classified as Expert and 16 as Novice. Statistically significant differences were found between the Expert and Novice groups for Overall Score (p=0.001), Safety (p=0.002) and Economy (p=0.033), but not Detailed Visualization (p=0.097). Questionnaire responses were positive for all items related to face and content validity.

CONCLUSION

This study suggests that training on the ArthroS™ VR hip arthroscopy simulator has construct, face and content validity. It expands the evidence base for VR simulator training and is the first study to evaluate this hip arthroscopy module.

Validation of joint angle measurements: comparison of a novel low-cost marker-less system with an industry standard marker-based system

Human motion tracking is widely used for the assessment of movement dysfunction in orthopaedic patients. Currently, most clinical motion analysis centres use marker-based three-dimensional (3D) systems as they are deemed to be the most accurate method. However, due to space, costs and logistics they are not available in many clinical settings. This study compared joint angles measured in functional tests using the novel low-cost Microsoft Kinect Perfect Phorm system with the established marker-based Nexus VICON system. When measuring right and left knee flexion, the average difference between the VICON and Kinect Perfect Phorm measurement was 13.2%, with a SD of 19.6. Both overestimation and underestimation of the joint angle was recorded in different participants. Although the average percentage difference during hip abduction tests was lower at -3.9%, the range of error was far greater (SD = 75). From this, it can be concluded that the level of accuracy presented in the new low-cost Kinect Perfect Phorm system is not yet suitable for clinical assessments. However, for general tests of performance, and for tracking cases where absolute accuracy is less critical, future versions of this software may have a place.

Readability of Information on Smartphone Apps for Total Hip Replacement and Total Knee Replacement Surgery Patients

Background:

Readability is a vital component of health information and providing this material at an appropriate literacy level may positively influence patient experience.

Objective:

To assess the readability of the information provided within total hip replacement and total knee replacement apps to understand more about the impact this could have on patients.

Method:

A systematic search was conducted across the 5 most popular smartphone app stores: iTunes, Google Play, Windows Mobile, Blackberry App World, and Nokia Ovi. Apps were identified for screening if they: targeted total hip replacement or total knee replacement patients; were free of charge; and were in English. App readability assessment was conducted independently by 3 reviewers using the Gunning Fog Index, the Flesch Reading Ease Score, and the Flesch-Kincaid Grade Level.

Results:

Fifteen apps met the inclusion criteria. Only one app was found “easy to read” (My THR).

Conclusion:

Findings suggest that the overall readability of information provided is written at a level which is difficult for patients to comprehend. App developers should engage patients in the design process of their apps, in order to enhance patient experience and for the potential impact of these innovative health technologies to be truly realized.