Is preoperative elevated glycated hemoglobin (HbA1c) a risk factor for postoperative shoulder stiffness after posterior-superior rotator cuff repair?

Background

Postoperative shoulder stiffness (POSS) affects a large number of patients undergoing rotator cuff repair (RCR). Diabetes may increase the risk of POSS. Preoperative glycated hemoglobin (HbA1c) is a convenient measure of glucose control in this group. The aim of the present study was to determine a relationship between preoperative HbA1c and POSS in patients undergoing postero-superior RCR.

Methods

Two hundred fifty patients with full-thickness postero-superior rotator cuffs who underwent RCR were followed for 6 months. Pre- and post-operative external rotation with arm by the side at 3 and 6 months were measured. Patient demographics, tear characteristics, preoperative HbA1c level, and surgical details were recorded. Patients with subscapularis tears, concomitant instability, partial thickness tears, arthritis, and irreparable rotator cuff tears were excluded. Univariate and multivariate logistic regression were used to determine the association between patient characteristics and POSS at 6 months.

Results

At the end of 6 months, 16% (41/250) of patients had POSS. Multivariate analysis demonstrated an elevated preoperative HbA1c level was a statistically significant predictor of POSS at 6 months (odds ratio 7.04, P < .01) after posterior superior RCR. Lower preoperative external rotation (P = .02) and female sex (P < .01) were also risk factors associated with POSS. Age, hand dominance, worker's compensation claim status, etiology, and size of the tear, surgical technique, and additional treatments were not statistically significant predictors.

Conclusion

Elevated preoperative HbA1c level is associated with POSS after RCR. Measuring HbA1c preoperatively may assist clinicians to identify patients at risk of POSS. HbA1c is a modifiable parameter that could then be optimized preoperatively in order to improve outcomes.

Assessing operative delay and complications in hip fracture patients on anticoagulants and antiplatelets

Objectives

Hip fractures represent a prevalent geriatric cause of morbidity and mortality. The presence of multiple comorbidities requiring the use of an anticoagulant or antiplatelet medication adds complexity to management and influences outcomes. International guidelines suggest expedited surgery within 48 h; however, anticoagulant and antiplatelet medications commonly cause delays. Research exploring health outcomes in this group is unclear. Therefore, we aimed to determine the impact of anticoagulant and antiplatelet medications on operative delay and overall complications in hip fracture patients.

Methods

A retrospective cohort study of hip fractures was performed at a tertiary hospital over a 3-year period from 1st January 2018 to 31st December 2020. Data collected included demographics, time to surgery, length of stay, postoperative blood transfusion, venous thromboembolism, acute coronary syndrome, stroke, infections in hospital and 120-day mortality. Patients were categorised based on the use of direct oral anticoagulants, warfarin and antiplatelet medications.

Results

In total, 474 patients were included and 43.5% were on an anticoagulant or antiplatelet medication. Patients on these medications had more than twice the rate of operative delay (41.7% versus 17.2%, p < 0.001) with the greatest in the direct oral anticoagulant group (92.7% delay). After controlling for age and gender, this was still significant for direct oral anticoagulant (p < 0.001) and antiplatelet group patients (p = 0.02). These patients also had a 20% increased overall complication rate (p < 0.001). On subgroup logistic regression, the increased complication rate was noted in the direct oral anticoagulant group (p = 0.006) and the antiplatelet group (p < 0.001) but not in the warfarin group (p = 0.25). Time to surgery beyond 48 h was associated with a double increase in the odds of a postoperative complication (p = 0.005).

Conclusion

There is a significantly greater delay to surgery in hip fracture patients on anticoagulant or antiplatelet medications as well as a higher incidence of complications. Guidelines to expedite early safe surgery in this high-risk patient group are required.

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta-analysis

BACKGROUND

Orthopaedic surgery is largely successful; however, a proportion of patients are dissatisfied and report pain and poor function. Psychological factors have been shown to influence orthopaedic surgical outcomes. This systematic review and meta-analysis investigates the types and effectiveness of preoperative psychological interventions in elective orthopaedic surgery.

METHODS

A registered systematic review (PROSPERO CRD42017073833) was performed on literature (1960-January 2018) using eight databases. Prospective controlled clinical trials involving adult and adolescent elective orthopaedic surgery were included. Interventions examined included relaxation, cognitive behavioural therapy, hypnosis, emotional counselling and mixed psychotherapies; general procedural education was excluded. Outcomes extracted included pain, anxiety, quality of life and disability.

RESULTS

A total of 19 studies met the inclusion criteria (n = 1893 patients). Meta-analyses were performed for pain, anxiety and quality of life. Analysis did not find enough evidence to confirm reduction in post-operative pain (seven studies, 666 patients; g = -0.15 (95% CI -0.42, 0.13), P = 0.305). Pooled data from six studies on acute post-operative anxiety (589 patients) showed a moderate statistically significant benefit (g = -0.26 (-0.49, -0.03), P = 0.024). There was an improved quality of life (mental component) at longer term follow-up (g = 0.25 (0.02, 0.49), P = 0.034).

CONCLUSIONS

These studies provide evidence that psychological interventions have a positive effect on anxiety in the acute post-operative period, and on mental components of quality of life at longer term follow-up.

Giant lumbar pseudomeningocele after revision lumbar laminectomy: a case report and review of the literature

Introduction

Incidental durotomy is a relatively common complication of spine surgery. Prevalence ranges from 3 to 5% in primary and 7 to 17% in revision procedures. Despite this relatively common occurrence the subsequent development of pseudomeningoceles following lumbar spine surgery is reported to be between 0.07 and 2%. Giant pseudomeningoceles (GP) are rare and therefore we report our experience with a case.

Case presentation

We report a case of an iatrogenic GP post revision lumbar surgery that extended 19 cm in length. The patient underwent revision L3-S1 laminectomy, laminotomy, excision of pseudomeningocele and successful direct dura repair. Postoperatively, a subcutaneous seroma persisted. This was managed with surgical exploration and prolonged drainage. This led to reduction of the seroma and symptomatic improvement for the patient.

Discussion

Incidental durotomy is a relatively common complication of spine surgery and if the durotomy is not addressed at the time of an operation a pseudomeningocele may develop. A pragmatic approach for GP is to individualise management based upon symptoms. Although GP are rare, prevention is likely the best approach. We outlined a structured approach to the management of an incidental dural leak that formed the largest reported pseudomeningocele reported to date.

Are Australian medical students being taught to teach?

BACKGROUND

The current global trend of growth in medical training is increasing the demand for the teaching and supervision of medical students and junior doctors. If well trained and supported, junior doctors and medical students represent an important teaching resource. Unfortunately, there is limited evidence available on whether Australian medical students are equipped with teaching skills. This study aimed to gain insight into the type and amount of teaching-skills training and peer-to-peer teaching present in Australian medical schools.

METHODS

A survey of Australian medical schools was conducted between May and December 2014. An online 22-item questionnaire was sent to all 19 Australian medical schools.

RESULTS

The response rate to the questionnaire was 100 per cent. Eleven Australian medical schools reported offering a teaching-skills programme, of which five were described as compulsory formal programmes. Eight schools did not offer such a programme, citing time restraints and other subjects taking higher priority. Formal peer-to-peer teaching opportunities were described by 17 schools, with 13 offering this electively. Two schools reported that they did not offer such opportunities because of time restraints, the belief that the quality of expert teaching is superior and because of a lack of staffing. The demand for the teaching and supervision of medical students and junior doctors is increasing CONCLUSIONS: Despite the increasing number of medical students and subsequently junior doctors in Australia, a minority of Australian medical schools report including a formal, compulsory teaching-skills programme. These results may imply a lost opportunity to use the positive effects of teaching-skills programmes, and are in line with studies from other countries.

Literature review of teaching skills programs for junior medical officers

OBJECTIVE

The aim of this review was to assess the current evidence regarding the efficacy of teaching skills programs for junior medical officers. We aimed to compare and contrast these results with findings from previous literature reviews, the last of which were published in 2009.

METHODS

In order to capture studies since the last published literature reviews, five databases and grey literature were searched for publications from January 2008 to January 2015. A search for literature reviews without using the timeframe limitation was also performed.

RESULTS

The search from January 2008 to January 2015 resulted in the inclusion of 12 studies. Five systematic reviews of the topic were found which included 39 individual studies that were also analysed. Nearly all studies reported positive effects. Twenty nine studies reported change in attitudes, 28 reported modification in knowledge, 28 reported change in behaviour, 6 reported change in the organisation and two reported change in program participant's students. There were substantial threats of bias present.

CONCLUSIONS

The literature reviewed demonstrated many positive effects of teaching skills programs, which supports their utilization. However, high level outcomes need to be evaluated over longer periods of time to establish their true impact. An organisation specific approach to these programs needs to occur using sound course design principles, and they need to be reported in evaluation trials that are designed with robust methodology.

Unassisted childbirth: why mothers are leaving the system

Unassisted childbirth is a topical subject that has sparked ethical and legal debate. Although there are little data surrounding unassisted birthing practice, concerns over consent, procedural intervention and loss of the birthing experience may be driving women away from formal healthcare. The healthcare system needs to work toward understanding this practice and, perhaps with the support of legislation, address the concerns of mothers in order to ensure optimal childbirth outcomes.