Development and Service Evaluation of an ad hoc Virtual Arthroplasty Clinic during COVID-19: Experiences from Irish National Orthopaedic Hospital.

Introduction: COVID-19 has had a significant impact on healthcare. It has forced orthopaedic surgeons to limit face-to-face patient contact. This resulted in the ad hoc creation of a virtual arthroplasty clinic (VAC) in Irish National Orthopaedic Hospital. We aimed to assess this new VAC and ascertain its effectiveness as an alternative to physical appointments during and following the pandemic. Materials and methods: Patients were followed-up in this VAC six weeks post-operatively. A service evaluation of this virtual arthroplasty clinic was carried out using a questionnaire created by the orthopaedic department. Results: A total of 30 patients requiring 6-week follow-up after the arrival of COVID-19 in Ireland were included. Average pre- and post-operative visual analogue scale score (VAS) was 8.1 and 2.3, respectively. Average pre- and postoperative Oxford hip and knee score was 19.1 and 39.2, respectively. Twenty-one patients (70%) were happy to have their six weeks post-operative e-outpatient consultation virtually. Twenty-six patients (86%) were happy with future virtual follow-up. Twenty-eight patients (93%) would be happy experiencing the whole process again. Eleven patients would be interested in having future joint replacement surgery, though ten of them (91%) stated COVID-19 would impact that decision. Conclusion: Most patients were happy to have their six-week appointment and future appointments virtually. Functional outcome scores had improved and pain scores had reduced at six-week follow-up, supporting the idea that virtual clinics are not inferior to physical clinics. Patients expressed concern about having a further joint replacement in the context of COVID-19.

Development and Service Evaluation of an ad hoc Virtual Arthroplasty Clinic during COVID-19: Experiences from Irish National Orthopaedic Hospital

@#Introduction: COVID-19 has had a significant impact on healthcare. It has forced orthopaedic surgeons to limit faceto-face patient contact. This resulted in the ad hoc creation of a virtual arthroplasty clinic (VAC) in Irish National Orthopaedic Hospital. We aimed to assess this new VAC and ascertain its effectiveness as an alternative to physical appointments during and following the pandemic. Materials and methods: Patients were followed-up in this VAC six weeks post-operatively. A service evaluation of this virtual arthroplasty clinic was carried out using a questionnaire created by the orthopaedic department. Results: A total of 30 patients requiring 6-week follow-up after the arrival of COVID-19 in Ireland were included. Average pre- and post-operative visual analogue scale score (VAS) was 8.1 and 2.3, respectively. Average pre- and postoperative Oxford hip and knee score was 19.1 and 39.2, respectively. Twenty-one patients (70%) were happy to have their six weeks post-operative e-outpatient consultation virtually. Twenty-six patients (86%) were happy with future virtual follow-up. Twenty-eight patients (93%) would be happy experiencing the whole process again. Eleven patients would be interested in having future joint replacement surgery, though ten of them (91%) stated COVID-19 would impact that decision. Conclusion: Most patients were happy to have their sixweek appointment and future appointments virtually. Functional outcome scores had improved and pain scores had reduced at six-week follow-up, supporting the idea that virtual clinics are not inferior to physical clinics. Patients expressed concern about having a further joint replacement in the context of COVID-19.

Is it safe for patients to drive after intra-articular knee injection?

BACKGROUND: Intra-articular knee injection is a central component in the current management of knee pain. While this is a routinely performed outpatient procedure, institutional policies for driving post injection differ. This study examines brake response times (BRTs) before and after intra-articular knee injection. Our hypothesis is that BRTs would not significantly differ and thus patients driving ability/safety is unaffected. METHODS: Forty-five patients previously listed for right intra-articular knee injection were prospectively evaluated. Patients underwent baseline assessment of BRT prior to injection. All patients received 10 ml of fluid consisting of one milliliter of 10 mg/ml triamcinolone mixed with nine milliliters of 0.5% levobupivacaine. BRT was re-examined on the same day prior to discharge home. Pre- and post-injection BRTs were examined using the same machine and assessor. RESULTS: The mean age of the cohort was 64.0 ± 12.4 and compromised of 37.8% males. There was no significant difference in the mean pre- and post-injection braking time (0.83 ± 0.29 vs 0.78 ± 0.30 s, p = .42), or in the rate of failed braking time (11.1% vs 6.7%, p = .46). CONCLUSION: This study found that BRT did not significantly differ before and after the intra-articular injection, nor did it cause an increased number of patients failing their BRTs. These findings suggest patients should not be prevented from driving after intra-articular knee injection.

Enhanced recovery protocols in total joint arthroplasty: a review of the literature and their implementation.

BACKGROUND: During recent years, there has been an exponential demand for joint arthroplasty, which has coincided with the global economic recession. In response, the management of patients following arthroplasty is continuously evolving, with the average inpatient length of stay decreasing from weeks to days, and more recently, we have witnessed the development of "outpatient arthroplasty" as a novel concept which aims to address the high volume of patients. The reduction in length of stay has been made possible via implementation of "enhanced recovery programmes" encompassing each stage of the patient journey. Such programmes have aimed to maximise efficiency, whilst maintaining patient satisfaction and achieving exceptional functional outcomes. OBJECTIVE: We have undertaken a thorough review the literature in relation to enhanced recovery programmes (ERPs) and the research that has underpinned individual elements of enhanced recovery. A literature search of enhanced recovery protocols was carried out using PubMed, Cochrane, Embase and OVID. No language restrictions were imposed on the search. REVIEW: ERPs represent a multifactorial framework which may be subdivided into several phases. Pre-operative education programmes, outpatient consultation, pre-anaesthetic assessment, pre-procedural physiotherapy, day-of-surgery admission, pre-operative medications, type of anaesthesia, blood loss reduction protocols, multimodal analgesia delivery, day-of-surgery mobilisation, thromboembolic prophylaxis and ongoing rehabilitation are essential in enhanced recovery. CONCLUSION: These successful strategies have streamlined the patient pathway of arthroplasty surgery in a cost-effective manner, whilst reducing length of hospital stay and maintaining patient outcomes. Further studies are required to appropriately quantify the impact of individual variables and development of an internationally agreed ERP.

Tomosynthesis: A new radiologic technique for rapid diagnosis of scaphoid fractures.

Scaphoid fractures constitute 71% of all carpal bone fractures.1 Early diagnosis and treatment has significant bearing on fracture union rates and better clinical outcomes. While displaced fractures can be readily seen on plain radiograph, undisplaced fractures can require advanced imaging modalities to confirm that diagnosis. Advanced imaging such as Magnetic Resonance Imaging (MRI), Computerised tomography (CT) and bone scintigraphy are routinely used for the diagnosis of scaphoid fractures but require significant radiation exposure, increased cost and can be difficult to access.2 Tomosynthesis is an emerging imaging modality which uses conventional x-ray systems to produce cross-sectional images. There has yet to be extensive research carried out investigating the diagnostic value of tomosynthesis in scaphoid fractures. The aim of this study is to optimise patient positioning for the diagnosis of scaphoid fractures in a cadaveric model and compare the diagnostic yield of tomography to conventional CT. Using four cadaveric specimens, three limb positions were examined in unfractured and fractured scaphoids to determine the optimal limb positions required for visualisation of the scaphoid. As a result of this study, the optimal position for visualisation of the scaphoid and diagnosis of scaphoid fractures has been determined. The results demonstrate that tomosynthesis is as effective as CT scanning in identifying scaphoid fractures in both sensitivity and specificity. By comparison to CT, tomosynthesis is cheaper, has lower radiation exposure, requires fewer hospital resources and can be performed quickly. Tomosynthesis is a valid diagnostic tool for the diagnosis of scaphoid fractures.

The aetiology of rickets-like lower limb deformities in Malawian children.

UNLABELLED: Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets. INTRODUCTION: Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities. METHODS: Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD. RESULTS: There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L. CONCLUSIONS: Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD.

Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis.

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head-shaft slip angle from 53.8(°) (standard deviation (SD) 3.2) pre-operatively to 9.1(°) (SD 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, SD 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

Post operative complications in a dedicated elective orthopaedic hospital: transfers requiring specialist critical care support.

We aim to report our experience with out of hospital transfers for postoperative complications in a stand-alone elective orthopaedic hospital. We aim to describe the cohort of patients transferred, the rate of transfer and assess the risk factors for transfer. Patients were identified who were transferred out of the hospital to another acute hospital for management of non-routine medical problems. Patient data was collected relating to age, BMI, ASA, type of surgery, nature of the complication, timing and the outcome of transfer. In 2012, 2,853 inpatient surgical procedures were carried out, 51 patients (1.8%) developed a postoperative complication that required out of hospital transfer. Mean age of patients transferred was 67 (12-86) years, mean age of the overall case mix 58 years (0-96) (p = 0.01). 37.7% of the overall case mix of surgeries was made up of primary hip and knee arthroplasty procedures, these patients made up 63.7% of patients transferred out (p = 0.001). Mean BMI recorded was 31.7 (22-48) compared to the mean BMI of the total arthroplasty case mix of 28.8 (20-44) (p = 0.02). 59% of all patients at our institution were ASA category II or III. 76% of patients transferred were ASA category II or III (p = 0.005). We can conclude that patients requiring transfer are typically older. Arthroplasty patients are more likely to require transfer than patients undergoing other orthopaedic procedures. Among the arthroplasty cohort transferred patients will typically have a higher BMI than average. Patients with ASA category II or III make up nearly three quarters of those patients transferred. The mean age of patients transferred is typically older by 9 years.

The Irish National Joint Registry: where are we now?

BACKGROUND: Ireland is currently in the process of establishing a National Joint Registry. AIM: We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland. METHODS: The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland. RESULTS: We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used. CONCLUSIONS: The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.

Risk factors for surgical site infection following operative ankle fracture fixation.

BACKGROUND: Ankle fracture is a common injury and there is an increasingly greater emphasis on operative fixation. AIM: The purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection. METHODS: A prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures. RESULTS: Univariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis. CONCLUSION: This study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.

Leucocyte esterase in the rapid diagnosis of paediatric septic arthritis.

Septic arthritis may affect any age group but is more common in the paediatric population. Infection is generally bacterial in nature. Prompt diagnosis is crucial, as delayed treatment is associated with lifelong joint dysfunction. A clinical history and application of Kocher's criteria may indicate that there is a septic arthritis. However, definitive diagnosis is made on culture of septic synovial fluid. The culture process can take over 24h for the initial culture to yield bacterial colonies. Leucocyte esterase is released by leucocytes at the site of an infection. We hypothesise that leucocyte esterase can be utilized in the rapid diagnosis of septic arthritis and shorten the time to decisive treatment whilst simultaneously decreasing unnecessary treatment of non-septic joints.

Evaluation in vitro of synthetic curcumins as agents promoting monocytic gene expression related to ß-amyloid clearance.

Accumulation of amyloid-beta (Aß) is one of the hallmarks of Alzheimer's disease (AD), and efficient clearance of Aß by cells of the innate immune system may be an important mechanism for controlling or preventing disease onset. It was reported that peripheral blood mononuclear cells (PBMCs) of most AD patients are defective in the phagocytosis of soluble Aß. Natural curcumins were shown to restore Aß phagocytosis by AD PBMCs and to up-regulate the expression of key genes including MGAT3 and those encoding Toll-like receptors (TLRs). Bisdemethoxycurcumin (BDC), a minor component of natural curcumin, was shown to have the greatest potency for stimulating AD PBMCs. Because natural curcumins have inherent limitations with regard to physicochemical properties, synthetic curcumin analogues were developed that showed improved solubility, stability, and bioavailability. An in vitro system using human monocytic cell lines (U-937, THP-1) was used to evaluate analogues for the potency of innate immune cell stimulation. These cell lines showed responses to curcuminoids and to 1α,25-dihydroxyvitamin D3 (VD3) resembling those seen in human PBMCs. From more than 45 curcuminoids analyzed, the most potent compounds possessing enhanced pharmaceutical properties were identified. The most promising candidates included prodrug versions containing water solubility-enhancing amino acids and stability-increasing modifications near the central diketone. In vivo studies showed compound (5) substantially increased bioavailability by combining several promising structural modifications. Studies examining ex vivo phagocytosis of Aß and bead particles in mouse microglia showed that BDC and several water-soluble analogues were quite effective compared to curcumin or an unnatural analogue. In vitro studies using monocytic cell lines reported herein complement those using human PBMCs and represent a routinely accessible and uniform cellular resource allowing direct comparisons between compounds.

Curcumins promote monocytic gene expression related to ß-amyloid and superoxide dismutase clearance.

Neurodegenerative diseases are associated with accumulation of modified proteins or peptides including amyloid-ß (Aß) in Alzheimer's disease (AD), and misfolded superoxide dismutase-1 (SOD-1) in amyotrophic lateral sclerosis (ALS). Clearance of Aß or SOD-1 by the innate immune system may be important for controlling or preventing disease onset. Curcumins restore Aß phagocytosis by peripheral blood mononuclear cells (PBMCs) from AD patients and Aß clearance with upregulation of key genes including MGAT3, vitamin D receptor (VDR) and Toll-like receptors (TLRs). Certain curcumins inhibit inflammatory processes of PBMCs from ALS patients. We developed an in vitro system using human monocytes from patients and monocytic cell lines (i.e. U-937, THP-1) for evaluating curcuminoid potency of innate immune cell stimulation. Bisdemethoxycurcumin and certain analogs potentiated MGAT3,VDR and TLR gene expression 3- to 300-fold in U-937 cells. The effect of curcumins on inflammation in monocytes from patients with ALS was examined. Recursive medicinal chemistry was applied to identify compounds that stimulate the innate immune system for use in the clearance of Aß in AD and the reversal of neuroinflammation and defective SOD-1 accumulation in ALS.

A prevalence study of errors in opioid prescribing in a large teaching hospital.

AIM: In 2007, the National Patient Safety Agency performed a study demonstrating that errors in prescribing led to nearly 12,000 adverse clinical incidents a year. The following year, they issued a rapid response report entitled 'Reducing Dosing Errors with Opioid Medicines' designed to be implemented by all NHS trusts. We performed a prevalence study to assess opioid prescribing errors in our large multi-speciality teaching hospital prior to implementation of these recommendations. METHODOLOGY: We conducted a 1 day snapshot of opioid prescriptions on inpatient drug charts. For every chart, all opioid information was entered into the study proforma. All data were reviewed by consensus group and errors categorised by quality and whether they were potentially lethal, serious, significant or minor. RESULTS: A total of 330/722 (46%) charts were found to have opioid prescriptions. On the study day, there were 74 charts with errors and on expert review another 16 erroneous charts were found giving a total of 90/330 (27.2%). The largest quality statement error group was 'unclear prescription, missing information'. There were 4 potentially lethal, 26 serious, 38 significant and 22 minor errors. DISCUSSION: Previous studies have reported opioid prescription error rates of 51.2-70%. Compared with the opioid literature, our trust fares well with an error rate of 27%- four of these errors being potentially lethal. This study has identified where there are weaknesses in our hospital opioid prescribing practice and has aided us in rewriting our acute and chronic pain guidelines with the explicit inclusion of the National Patient Safety Agency recommendations. We have also disseminated the study results at the Trust academic meeting and developed an opioid e-learning package which will be mandatory for all new staff.

The effect of inclement weather on trauma orthopaedic workload.

BACKGROUND: Climate change models predict increasing frequency of extreme weather. One of the challenges hospitals face is how to make sure they have adequate staffing at various times of the year. AIMS: The aim of this study was to examine the effect of this severe inclement weather on hospital admissions, operative workload and cost in the Irish setting. We hypothesised that there is a direct relationship between cold weather and workload in a regional orthopaedic trauma unit. METHODS: Trauma orthopaedic workload in a regional trauma unit was examined over 2 months between December 2009 and January 2010. This corresponded with a period of severe inclement weather. RESULTS: We identified a direct correlation between the drop in temperature and increase in workload, with a corresponding increase in demand on resources. CONCLUSIONS: Significant cost savings could be made if these injuries were prevented. While the information contained in this study is important in the context of resource planning and staffing of hospital trauma units, it also highlights the vulnerability of the Irish population to wintery weather.

The effects of introducing artemether-lumefantrine malaria treatment and insecticide-impregnated bed nets to an elective surgical hospital.

Malaria and anaemia in patients admitted for elective orthopaedic operations commonly cause delays to surgery. Our hospital has introduced artemether-lumefantrine as the standard treatment for malaria in accordance with the national policy, replacing sulphadoxine-pyrimethamine. Insecticide-impregnated bed nets were also introduced throughout our wards. A retrospective audit of all new elective surgical admissions over a 12-month period was performed in order to assess the effect of these changes. The study was designed to follow an identical audit performed before their introduction. Of the 435 patients admitted, 75 (17.2%) had malaria parasites present on blood film. In these patients, surgery was significantly delayed, by a mean of 9.9 days more than the group without malaria (P < 0.001). Before the changes to malaria treatment, the mean delay was 2.2 days (P < 0.05). Six patients (1.7%) developed malaria during admission, significantly fewer than the 16 (4.3%) before the introduction of bed nets (P = 0.036). The average haemoglobin level on admission in patients with malaria parasites was 11.8 g/dL (95% confidence interval [CI] 11.4-12.2) and in those without 13.1 g/dL (95% CI: 12.9-13.3). Seventeen patients (3.9%) were admitted with a haemoglobin concentration of <10 g/dL and two (0.5%) of <8 g/dL. There were no significant delays to surgery in these patients compared to those without anaemia. The adoption of artemether-lumefantrine by our hospital significantly increased delays to surgery. The introduction of insecticide-impregnated bed nets significantly reduced the number of patients developing malaria during their hospital stay.

Irish (Republic) versus British (North West) orthopaedic trainees: what are the differences?

British Trainees have gradually had their working week curtained over the last 8 years. The Republic of Ireland Trainees have not been subjected to the European Working Time Directive prior to 2009 and have therefore worked on average, more hours than their British counterparts. We wanted to see if the differing schemes had an impact on recruiting and training orthopaedic surgeons. We surveyed Republic of Ireland orthopaedic specialist registrars (SpRs) and North West (NW) British SpRs/specialist trainees (ST3 and above) to see if there were any discernable differences in working patterns and subsequent training exposure. A standard proforma was given to Irish Trainees and to NW SpRs/STs at their National or regional teaching (January/February 2009). 62% of Irish and 47% of British NW Trainees responded. Irish trainees were more likely to have obtained a post-graduate degree (p = 0.03). The Irish worked more hours per week (p < 0.001) doing more trauma operative lists (p = 0.003) and more total cases per 6 months than the NW British (p = 0.003). This study suggests that more hours worked, equals more operative exposure, without detriment to the academic side of training. Obviously it is not possible to say whether fewer operations make for a poorer surgeon, but the evidence suggests that it may be true.

Proactive integrated care improves quality of life in patients with COPD.

Self-management strategies improve a variety of health-related outcomes for patients with chronic obstructive pulmonary disease (COPD). These strategies, however, are primarily designed to improve chronic disease management and have not focused on early detection and early treatment of exacerbations. In COPD, the majority of exacerbations go unreported and treatment is frequently delayed, resulting in worsened outcomes. Therefore, a randomised clinical trial was designed to determine whether integration of self-management education with proactive remote disease monitoring would improve health-related outcomes. A total of 40 Global Initiative for Chronic Obstructive Lung Disease stage 3 or 4 COPD patients were randomised to receive proactive integrated care (PIC) or usual care (UC) over a 3-month period. The primary and secondary outcomes were change in quality of life, measured by the St George's Respiratory Questionnaire (SGRQ), and change in healthcare costs. PIC dramatically improved SGRQ by 10.3 units, compared to 0.6 units in the UC group. Healthcare costs declined in the PIC group by US$1,401, compared with an increase of US$1,709 in the UC group, but this was not statistically significant. PIC uncovered nine exacerbations, seven of which were unreported. Therefore, proactive integrated care has the potential to improve outcomes in chronic obstructive pulmonary disease patients through effects of self-management, as well as early detection and treatment of exacerbations.