The effect of early mobilization on functional outcomes after hip surgery in the Chinese population – A multicenter prospective cohort study

Objective To compare the functional status and quality of life (QoL) between patients who underwent an early mobilization scheme and those who underwent a late mobilization scheme after hip fracture fixation surgery in elderly Chinese patients. Methods This was a prospective cohort study. Patients (≥65 years old) with unstable intertrochanteric fractures treated with intramedullary nails were recruited from nine centers in China. Study centers either performed early mobilization or late mobilization scheme. All patients performed immediate in-bed mobilization after surgery and followed a standardized daily exercise program at home during the first 12 weeks. Functional status was measured by the Modified Barthel Index at postoperative visit, 6 weeks, and 12 weeks. QoL was measured by the EuroQol-5D (EQ-5D) at 12 weeks. Results One hundred and forty-eight patients were enrolled to early mobilization, and 136 to late mobilization. At 6 weeks, early mobilization resulted in a significantly better Modified Barthel Index than late mobilization (mean [SD]: 83.7 [12.0] vs. 67.0 [17.5], p < .001). Adjusted mixed effects model showed significantly higher Modified Barthel Index for early mobilization at postoperative visit, 6 weeks, and 12 weeks (all p < .001). Patients in the early mobilization group had slightly better EQ-5D Index at 12 weeks than patients in the late mobilization group (mean: 0.91 vs 0.87, p = .002). Conclusions Early postoperative mobilization resulted in better functional outcomes up to 12 weeks. QoL was rated statistically significantly better in the early mobilization group, but the difference was small and may not be clinically relevant.

Complete Vision Loss after Laparoscopic Hysterectomy

Postoperative vision loss (POVL) is a rare but devastating complication that has only recently been reported following laparoscopic surgery. We present the case of a 34-year-old gravida 6 para 4 female who experienced POVL following an uncomplicated laparoscopic hysterectomy. Operating time was 174 minutes, and EBL was 75 mL. After surgery, she complained of complete vision loss with no light perception. No cerebral hemorrhage or ischemia was detected on imaging. Funduscopic exam revealed no structural abnormalities. On postoperative day 7, she received an IV methylprednisolone taper. The following morning, she reported mild light perception. Later that night, she reported a partial return of visual acuity and was discharged home. At her 2-week postoperative visit, her vision had returned to baseline. POVL is an emergency and prompt evaluation should be initiated to optimize outcome.

Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients

Introduction Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery. Methods Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients’ first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively. Results At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use. Conclusion Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use. Level of Evidence: Level III

Laryngeal Force Sensor for Suspension Microlaryngoscopy: A Prospective Controlled Trial

Objectives The laryngeal force sensor (LFS) provides real-time force data for suspension microlaryngoscopy. This study investigates whether active use of the LFS can prevent the development of complications. Study Design Prospective controlled trial. Setting Academic tertiary center. Methods The LFS and custom software were developed to track intraoperative force metrics. A consecutive series of 100 patients had force data collected with operating surgeons blinded to intraoperative readings. The subsequent 100 patients had surgeons actively use the LFS monitoring system. Patients were prospectively enrolled, completing pre- and postoperative surveys to assess the development of tongue pain, paresthesia, paresis, dysgeusia, or dysphagia. Results On univariate analysis, the active monitoring group had lower total impulse ( P < .001) and fewer extralaryngeal complications ( P < .01). On multiple logistic regression, maximum force (odds ratio [OR], 1.08; 95% CI, 1.01-1.16; P = .02) was a significant predictive variable for the development of postoperative complications. Similarly, active LFS monitoring showed a 29.1% (95% CI, 15.7%-42.4%; P < .001) decrease in the likelihood of developing postoperative complications. These effects persisted at the first postoperative visit for maximum force ( P = .04) and active LFS monitoring ( P = .01). Maximum force (OR, 1.11; 95% CI, 1.04-1.18; P < .01) and active LFS monitoring (16.6%; 95% CI, 2.7%-30.5%; P = .02) were also predictive for the development of an abnormal 10-item Eating Assessment Tool score. These effects also persisted at the first postoperative visit for maximum force ( P = .01) and active LFS monitoring ( P = .01). Conclusion Maximum force is predictive of the development postoperative complications. Active monitoring with the LFS is able to mitigate these forces and prevent postoperative complications. Level of Evidence 2.

The influence of anesthesiologist postoperative visit on patient satisfaction with anesthesia for reconstruction of the anterior cruciate knee ligament

Background / Aim. Patient satisfaction, when it comes to anesthesia, is more difficult to assess than in any other medical specialty. The aim of this study was to construct a tool for assessing patients' satisfaction with anesthesia, and then examine the effects of post-operative care provided by anesthesiologists on patients? satisfaction. Methods: The study included patients undergoing general anesthesia, who were considered ASA 1 and ASA 2 class. Patients were divided into three groups: Group 1 included 74 patients who had postoperative visit performed by an attending anesthesiologist; Group 2 included 70 patients who had postoperative visit performed by a nurse anesthetist after surgery; and Group 3 included 74 patients who did not have postoperative visit during post-operative care by an anesthesiologist nor a nurse anesthetist. The tools used in the research were Anesthesia patient satisfaction questionnaire specially designed for this study and Post Anesthetic Recovery Scoring System (PAS). ANOVA and Pearson?s correlation coefficient were used for estimating the statistical significance of the obtained results between the groups. Results: Association between an objective assessment of the post-operative status of patients on day zero and satisfaction with the anesthesiologist's patient management shows statistical significance (p<0.05). Patients who had a post-operative visit by an anesthesiologists tolerated better preoperative and postoperative physical symptoms. Patients visited by an anesthesiologist were most satisfied with post-operative care (p<0.05). Conclusion: Use of a highly reliable questionnaire for evaluation of patient?s satisfaction with anesthesia could improve the post-operative condition of patients and enable faster recovery during post-operative period.

A Multimodal Pain Management Regimen Utilizing Adductor Canal Block in a Veterans Affairs Population Decreases Opioid Consumption Following Total Knee Arthroplasty.

Background: Ease of access to opioids in the perioperative period is a risk factor for subsequent opioid abuse. The purpose of this study was to quantify a decrease in opioid consumption following implementation of a new analgesic protocol after total knee arthroplasty (TKA). Methods: A retrospective cohort study was performed analyzing patients who underwent TKA at a Veterans Affairs medical center. Patients were divided into two groups by multimodal analgesic regimen: Analgesia with intraoperative general anesthesia, a patient controlled analgesia pump, and oral opioids (Traditional group) or analgesia with intraoperative spinal anesthesia, a multimodal medication regimen, and an adductor canal block (Protocol group). Results: A total of 533 TKAs were included. The intravenous morphine equivalent dose (MED) requirement was 178.2 ± 98.0 for Traditional and 12.0 ± 24.6 for Protocol groups (p < 0.001). Total opioid MED requirement was 241.7 ± 120.1 for Traditional and 74.8 ± 42.7 in Protocol groups (p < 0.001). The Protocol group required only 6.7% of the intravenous opioids and 30.9% of the total opioids used by the Traditional group. No difference in oral opioid requirements was found (p = 0.849). The Traditional group required more opioid refills at the first postoperative visit (p < 0.001). Conclusions: The described analgesic protocol resulted in significant decreases in intravenous and total opioid requirement, and lower rates of opioid prescriptions at the first postoperative visit. These findings demonstrate a decrease in opioid utilization with modern perioperative analgesia protocols and reinforce recommendations by the CDC and AAOS to decrease opioid exposure and access. Trial Registration: Not applicable

Long-term refractive outcomes in patients with cataracts and keratoconus after phacoemulsification with toric intraocular lens implant

Purpose: To determine the refractive stability of patients with keratoconus and cataracts after the implantation of a toric intraocular lens. Methods: This is a cross-sectional, retrospectivestudy. Clinical records from patients with non-progressive keratoconus and cataracts that underwent non-complicated phacoemulsification with toric IOL implantation were reviewed. Mean keratometry (Km), refractive cylinder (RC), spherical equivalent (SE), steeper keratometry (K), and axis were evaluated at the 1-month, 6-month, 12-month, and 24-month follow-up visits. Results: Fifty-four eyes from 41 patients were included. Thirty-seven (68.5%) female and 17 (31.5%) male patients, with a mean age of 67.52 ± 8.22. Refractive cylinder at postoperative 30 days was −1.61 ± 1.23, 6-month −1.22 ± 0.80, 12-month −1.10 ± 0.83 and 24-month visit after surgery was −1.37 ± 0.77( p = 0.290). SE at the 30-day visit was −0.82 ± 1.90, 6-month −0.64 ± 1.23, 12-month −0.78 ± 1.91 and at 24-month postoperative visit −1.02 ± 1.87 ( p = 0.210). Km value at the 1-month visit was 47.23 ± 1.95, 6-month 47.87 ± 1.61, 12-month 46.39 ± 2.52 and 24-month postoperative visit 46.92 ± 1.26 ( p = 0.877). The steeper K axis in the 30-day control was 78.53 ± 30.12, 6-month 77.29± 37.68, 1-year 93.13 ± 62.42, 24-month 67.31 ± 38.49 ( p = 0.632). Conclusions: Our findings suggest a low variation in the refractive outcome for patients with mild and moderate keratoconus and cataracts, without evident progression signals, a demonstrated keratoconus clinical stability. No statistically significant postoperative changes in the refractive cylinder, SE, mean K, and steeper K axis were observed, which suggests good predictability for toric IOL implant.

Virtual Reality as Distraction Analgesia for Office-Based Procedures: A Randomized Crossover-Controlled Trial

Objective The purpose of this study was to explore the use of immersive and interactive virtual reality (VR) for analgesia, anxiety reduction, and overall satisfaction in patients undergoing outpatient postoperative debridements. Study Design Randomized crossover-controlled trial. Setting Academic outpatient clinic. Subjects and Methods Adult patients who had functional endoscopic sinus surgery and skull base surgery and were undergoing office-based postoperative nasal endoscopy and debridement were recruited and followed for 2 consecutive office visits. Participants were randomized to receive either the control or experimental analgesia for the first postoperative visit (PO1) and crossed over into the opposite treatment arm during the second postoperative visit (PO2). Outcomes included procedural pain, anxiety and satisfaction scores, procedural time, and reflexive head movements per minute (RHM). Results Eighty-two participants were recruited. At PO1, 39 received standard analgesia, and 43 received an immersive VR experience. At PO1, the VR group experienced significantly less anxiety ( P = .043) and fewer RHM ( P = .00016) than the control group. At PO2, the VR group experienced significantly fewer RHM ( P = .0002). At PO2, patients who received the experimental treatment after initially receiving the control treatment had significantly decreased pain, anxiety, and RHM. This effect was not seen in the second group. Overall, 69.51% of patients felt that the VR treatment was better; 19.51% thought that it was the same; and 9.76% found it to be worse. Conclusion VR technology holds promise as a nonpharmacologic analgesic and anxiolytic intervention for otolaryngology office-based procedures. Further study of VR use in other procedures is warranted. Level of Evidence: 1, randomized controlled trial.

The burden and utility of routine follow-up at one year after primary arthroplasty

Aims Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers. Methods All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit. Results Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed. Conclusion Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85–89.