Patient perspectives on elective orthopaedic surgery during the COVID-19 pandemic: a comparison between patients from different ethnic backgrounds

INTRODUCTION

Suspending elective surgery during the first wave of coronavirus (COVID-19) led to record-breaking numbers of patients on waiting lists. Patients in Black, Asian and minority ethnic (BAME) groups are disproportionately affected by COVID-19. This study compares the perspectives of patients from different ethnic backgrounds on the return to elective surgery.

METHODS

Some 151 patients were sampled from cancelled operating lists at two hospitals. Semi-structured interviews focused on the impact of COVID-19, and views about resuming elective surgery. The Generalized Anxiety Disorder 7-iten Scale (GAD-7) measured anxiety. A visual analogue scale (VAS) measured pain. Data were analysed using exploratory thematic analysis.

RESULTS

Fewer BAME patients were pleased about restarting surgery, compared with white patients (47.3% vs 82.6%, p<0.001), and a greater proportion wanted to postpone their operation until after the pandemic (21.8% vs 9.3%, p=0.048). White/white British patients had higher GAD-7 scores (2 (0-21) vs 0 (0-16), p=0.009). Black/Black British patients had significantly higher VAS scores compared with white/white British and Asian/Asian British patients (85 vs 75 vs 70 respectively, p<0.05).

CONCLUSION

The delay in surgery due to the pandemic has had a devastating impact on patients awaiting operations. The variation in pain and anxiety levels between ethnic groups must be addressed when redesigning services to avoid discrepancies in postoperative clinical outcomes. Patients in BAME groups are more likely to postpone their operation, which may lead to further health deterioration, psychosocial and socio-economic consequences, and poorer clinical outcomes following surgery. The thoughts, feelings and concerns of all must be considered when redesigning services to prevent health inequalities between patients from different backgrounds.

A 3 year minimum follow up of Endoprosthetic replacement for distal femoral fractures - An alternative treatment option

INTRODUCTION

Although the use of an endoprosthesis for distal femoral fractures remains a valid treatment option the widespread use is in its infancy.

METHODOLOGY

In this retrospective case series, we review cases of distal femoral fracture treated with endoprosthetic replacement (EPR). The outcomes we assessed were the time to start mobilising, the time to discharge, morbidity and mortality as well as an Oxford knee score to assess pain and function and also the early survivorship. 6 of the 11 from the cohort had existing Total Knee Replacements (TKRs) in situ.

RESULTS

There were 11 knees in our cohort with a mean age of 81.5 years (range 52-102 years). The median time to follow up was 3.5 years (range 1.6 to 5.5 years). The median times to theatre was 3 days and to discharge was 16 days. Oxford functional and pain scores were 32/48.

DISCUSSION

In the appropriate patient and fracture pattern, Endoprosthetic knee replacement is an excellent option in the treatment of distal femoral fractures whether associated with an existing TKR or not. The implant is more costly than traditional open reduction and internal fixation, but the earlier return to full mobility post-operatively may save on hospital/care home stay and free up hospital space and minimise complications.

[Limb salvage and amputation after trauma : Decision criteria and management algorithm]

The clinical decision-making process for patients with severe trauma of the extremities for primary amputation or to initiate extensive reconstructive measures for limb salvage in the best interests of the patient can be complex and difficult. The many factors influencing the decision-making process, such as local anatomical, pathomechanical, physiological, psychosocial and general factors are demonstrated and discussed. In the past, the role of scores supporting the decision-making process for amputation or limb salvage has been overestimated. In the LEAP study it could clearly be demonstrated that none of the sometimes highly complex scores could fulfill the expectations to predict successful limb salvage or the need for amputation. In this article it is shown that initiators and authors of scores achieved much higher sensitivity and specificity in the inaugural studies compared to the standardized and controlled conditions used in the LEAP study. For a long time, a lack of feeling in the feet was considered a safe and reliable criterion for amputation but the LEAP study has made a substantial contribution to demythologizing this as a lead symptom. Patients with severe trauma of the ankle or foot requiring a free flap or ankle arthrodesis have a significantly worse outcome compared to patients with a below knee amputation. Taking all these influencing factors into consideration, a comprehensive algorithm is presented that facilitates, strengthens and standardizes decision-making for amputation or limb salvage. This algorithm consists of four modules: 1) decision-making, 2) emergency treatment, 3) definitive treatment and 4) fine tuning. In the decision-making module not only local and general injury severity are addressed but the expected result, the general condition, comorbidities, compliance and the will of the patient are also included.

Early management of proximal humeral fractures with hemiarthroplasty: a systematic review

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7 degrees (10 degrees to 180 degrees) and the mean abduction to 92.4 degrees (15 degrees to 170 degrees). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.

External fixation devices in the treatment of fractures of the tibial plafond

We have compared the outcomes of the use of external fixation devices for spanning or sparing the ankle joint in the treatment of fractures of the tibial plafond, focusing on the complications and the rates of healing. We have devised a scoring system for the quality of reporting of clinical outcomes, to determine the reliability of the results.

We conducted a search of publications in English between 1990 and 2006 using the Pubmed search engine. The key words used were pilon, pylon, plafond fractures, external fixation. A total of 15 articles, which included 465 fractures, were eligible for final evaluation.

There were no statistically significant differences between spanning and sparing fixation systems regarding the rates of infection, nonunion, and the time to union. Patients treated with spanning frames had significantly greater incidence of malunion compared with patients treated with sparing frames. In both groups, the outcome reporting score was very low; 60% of reports involving infection, nonunion or malunion scored 0 points.

The biological and physiological effects of intramedullary reaming

This paper summarises the current knowledge on the effects of medullary reaming of long-bone fractures. Following a review of intramedullary vascular physiology, the consequences for vascularity, the autograft effects, the generation of heat, and fat embolism are outlined. Also, alternative reaming techniques are described.

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group

BACKGROUND

Damage control orthopedic surgery has recently been advocated for the management of femoral shaft fractures in severely injured patients because surgical procedures were found to represent a second-hit phenomenon regarding the operative burden. It has been attempted to determine the operative burden by means of proinflammatory cytokines. In this study in clinically stable patients with multiple injuries, the effects induced by different types of primary fracture stabilization on the systemic release of proinflammatory cytokines were evaluated.

METHODS

This was a prospective, randomized, multicenter intervention study. Inclusion criteria were long bone shaft fracture of the lower extremity; age 18 to 65 years; Injury Severity Score > 16 or more than three extremity injuries (Abbreviated Injury Scale [AIS] score of 2 or more) in association with another injury (AIS score of 2 or more); and thoracic AIS score < 4. After informed consent, randomization for the treatment of the femoral shaft fracture was performed at admission. Groups were as follows: group I degrees FN (primary, < 24 hours) intramedullary nailing, and group DCO (DCO, I degrees ex.fix.) damage control orthopedic surgery and external fixation. In DCO patients, measurements were also performed at the time of conversion to the intramedullary procedure (DCO II degrees FN). Parameters included clinical parameters and complications (acute respiratory distress syndrome, multiple organ failure, sepsis). From serially sampled central venous blood, the perioperative concentrations of interleukin IL-1, IL-6, and IL-8 were determined. RESULTS Thirty-five patients were included (I degrees FN, n = 17; DCO, n = 18). In I degrees FN-patients, a perioperative increase of IL-6 levels was measured (preoperatively, 55 +/- 33 pg/dL; 24 hours postoperatively, +254 +/- 55 pg/dL; p = 0.03), which was not found in subgroup DCO I degrees Ex.fix.: preoperatively, 71 +/- 42 pg/dL; 24 hours postoperatively, 68 +/- 34 pg/dL; not significant [NS] or in group DCO II degrees FN: preoperatively, 36 +/- 21 pg/dL; 24 hours postoperatively, +39 +/- 25 pg/dL; NS. Likewise, in I degrees FN patients, a perioperative increase of IL-8 levels was measured only at the 7-hour time point (preoperatively, 35 +/- 29 pg/dL; 7 hours postoperatively, 95 +/- 23 pg/dL; p < 0.05), which was not found in group DCO I degrees Ex.fix.: preoperatively, 43 +/- 38 pg/dL; 24 hours postoperatively, 69 +/- 39 pg/dL; NS or in group DCO II degrees FN: preoperatively, 25 +/- 20 pg/dL; 24 hours postoperatively, 36 +/- 29 pg/dL; NS. There were no differences in the complication rate in terms of acute respiratory distress syndrome, sepsis, or multiple organ failure.

CONCLUSION

In this prospective, randomized, multicenter study, a sustained inflammatory response was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. These findings may become clinically relevant in patients at high risk of developing complications. It confirms previous studies in that damage control orthopedic surgery appears to minimize the additional surgical impact induced by acute stabilization of the femur.