Accelerometer-Based Handheld Navigation Instrumentation in Total Knee Arthroplasty Decrease Blood Loss Compared to Conventional Instrumentation: A Prospective Comparative Study

Aim: To assess adherence on recommended guidelines for pre-operative routine investigations in ASA grade 1 and 2 by anaesthesiologists. Study Design: Cross-sectional study Place and Duration of Study: Tertiary Care Hospitals in the Province of Sindh from 17th April 2019 to 17th October 2019. Methodology: One hundred anaesthesiologists were enrolled. The laboratory investigations of the patients which were ordered by anaesthesiologists according to ASA Grade I & II and surgical grade I & II depending upon the age (16-60). The investigations were classified into three categories Good, Acceptable and Poor depending upon adherence to NICE guidelines. Results: Sixty six (66%) were males and 34 (34%) were female and the median age was 31 (29-35). Only 16% were positive adherence to the NICE guidelines when ordering pre-operative routine investigations which falls under category of poor adherence while none of positive adherence fall under category of good or acceptable adherence. Traditionally, there is no recommended test for ASA I, surgery grades I & II and ASA II, surgery grade I, but the result indicates that several insignificant tests were requested in these classes. Conclusion: Preoperative biochemical testing is widely used and enhance the effectiveness of surgery but it should be cost effective in range of the patients. Keywords: Tertiary care hospitals, Adherence, Routine investigations, Guidelines

AimsThe safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery.MethodsThis is a prospective study of 121 patients who underwent elective orthopaedic procedures through a COVID-free pathway. All patients underwent a 14-day period of self-isolation, had a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-free site. Baseline patient characteristics were recorded including age, American Society of Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type. Patients were contacted 14 days following discharge to determine if they had had a positive COVID-19 test (COVID-confirmed) or developed symptoms consistent with COVID-19 (COVID-19-presumed).ResultsThe study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years ± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70 patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19 test in the postoperative period. One patient (0.8%) developed anosmia postoperatively without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and self-isolated for seven days. Her symptoms resolved within a few days.ConclusionThe development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. While both surgeons and patients should remain vigilant, elective surgery can be safely restarted using dedicated pathways and procedures.Cite this article: Bone Joint Open 2020;1-9:562–567.

Introduction:Since the advent of antifibrinolytics, blood transfusions and their associated complications in total joint arthroplasty have decreased. Few studies have compared different antifibrinolytic types with respect to blood loss and transfusion rates. We sought to compare the blood loss and transfusion rates between epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), and control.Methods:A total of 564 patients underwent primary total hip or total knee arthroplasty at our institution. Patients were divided into 3 groups: 183 EACA, 204 TXA, and 177 control. Patient demographics, hemoglobin, transfusion rates, and blood loss were collected.Results:Patient preoperative variables were similar. The control group had a mean estimated blood loss (EBL) of 1.48 L, with 51 units of packed red blood cells (pRBCs) given and 14.7% of patients receiving a blood transfusion. The EACA group had an EBL of 1.33 L, with 20 pRBCs given and 10.9% of patients receiving a transfusion. The TXA group had an EBL of 1.05 L, with 3 pRBCs transfused in 0.98% of patients. Compared with the control group, blood loss (P = 0.0014; P < 0.0001), number of pRBCs given (P = 0.007; P < 0.0001), and number of patients transfused (P = 0.012; P < 0.0001) were significantly lower in the EACA and TXA groups, respectively. TXA had significantly lower blood loss (P < 0.0001), lower number of tranfusions (P = 0.005), and less patients transfused (P = 0.003) compared with EACA.Conclusion:Our study reports lower blood loss, transfusion rates, and number of patients needing transfusion with both EACA and TXA in the setting of total joint arthroplasty. When comparing between EACA and TXA, TXA had lower blood loss, transfusion rates, and number of patients requiring transfusion.

Introduction: Post-spinal Anaesthesia Shivering (PSAS) refers to involuntary, repetitive skeletal muscle contractions triggered by a fall in core body temperature that generate heat but can cause significant discomfort, increase intracranial and intraocular pressures and raise oxygen demand with potential clinical consequences. Aim: To assess the efficacy of two intravenous (i.v.) doses of dexmedetomidine, administered prior to spinal anaesthesia, in preventing PSAS in patients undergoing lower limb orthopaedic procedures. Materials and Methods: This double-blinded, randomised controlled study was conducted at Department of Anaesthesia, King George’s Medical University, Lucknow, Uttar Pradesh, India in collaboration with the Department of Orthopaedics, for a period of 12 months, from October 2022 to September 2023. A total of 75, American Society of Anaesthesiologists (ASA) physical status grade I/II patients were scheduled for elective lower limb orthopaedic surgeries after ethical approval. Participants were randomly assigned to three groups (n=25 each) via a computer-generated sequence: Group I received 100 mL of normal saline; Group II received dexmedetomidine 0.25 μg/kg diluted in 100 mL saline; and Group III received dexmedetomidine 0.5 μg/kg in 100 mL saline. Infusions were administered over 10 minutes. Blinding was maintained for both the administering and observing anaesthesiologists. Categorical data (gender, ASA grade, incidence of shivering, consumption of tramadol) was analysed using Chi-square tests and continuous data {age, height, weight, Body Mass Index (BMI), duration of surgery and spinal anaesthesia, onset of shivering after spinal anaesthesia, temperature, Ramsay sedation score, Heart Rate, (HR) Systolic Blood Pressure (SBP)} was analysed using Analysis of Variance (ANOVA) tests, with level of significance (p-value&lt;0.01) considered as statistically significant. Results: Demographic variables (age, gender, weight, height, BMI, ASA status and duration of surgery) were comparable across the three groups, in terms of their p-value. The mean onset time of shivering, tramadol consumption and post-spinal temperature fall were not statistically significant. The mean Ramsay sedation score at 10 minutes was highest in group III (3.8±0.98), followed by group II (2.4±0.82) and group I (1.8±0.69), showing a highly significant difference (p-value&lt;0.0001). HR and SBP declined after spinal anaesthesia and rose again at the time of shivering in all groups, with statistically significant differences observed between groups. The duration of spinal anaesthesia increased progressively from group I (153.12±2.84 min) to group II (168.32±3.24 min) and group III (171.44±3.98 min) (p-value&lt;0.0001), while the incidence of adverse events was infrequent. Conclusion: Preoperative i.v. dexmedetomidine effectively reduces the incidence of shivering following spinal anaesthesia. A lower dose (0.25 μg/kg) is associated with fewer sedative and cardiovascular effects and may be preferable for routine use.

The effect of previous abdominal surgery on urological laparoscopy.

Antifibrinolytic agents have been shown to decrease the blood loss associated with major orthopaedic surgical procedures. Spine surgery, particularly procedures performed for deformity correction and procedures involving long arthrodesis constructs, can be associated with a large amount of blood loss requiring blood transfusions. The purpose of the present study was to determine if antifibrinolytic agents reduced blood transfusions in patients managed with spine surgery and to see if one agent had a greater effect than another. A systematic review and meta-analysis of the available literature were performed to investigate the efficacy of aprotinin, tranexamic acid, and epsilon-aminocaproic acid in terms of reducing blood loss and blood transfusions in patients undergoing spine surgery. This meta-analysis was focused on the role of these agents in major spine operations as reported in eighteen clinical trials that included information on the drug dosage, the age of the patient, blood loss, blood transfusions, surgery complexity, and complications. Compared with control groups, the treatment groups for all three antifibrinolytic agents maintained lower levels of total blood loss and transfusions associated with spine surgery. The effect size (d) of the differences in total blood loss between the treatment and control groups ranged from -0.668 (95% confidence interval, -0.971 to -0.365) to -0.936 (95% confidence interval, -1.240 to -0.632) across all three agents. The effect size (d) of the differences in total blood transfusions between the treatment and control groups ranged from -0.466 (95% confidence interval, -0.764 to -0.167) to -0.749 (95% confidence interval, -1.046 to -0.453) across all three agents. Aprotinin, tranexamic acid, and epsilon-aminocaproic acid are effective for reducing blood loss and transfusions in patients managed with spine surgery. With the exception of aprotinin, the side-effect profiles of these agents have not been shown to cause any substantial morbidity or to increase the rate of thromboembolic events. Epsilon-aminocaproic acid had a greater effect on reducing blood transfusions as the complexity of surgery increased. The surgeon and/or the anesthesiologist should consider the use of antifibrinolytic agents for patients undergoing spinal procedures in which a large amount of blood loss can be expected; however, at the present time, this is not a United States Food and Drug Administration-approved indication for these agents.

A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire.

Introduction: Femur fractures in elderly patients present unique challenges for anaesthetic management. Spinal anaesthesia with adjuvants has emerged as a preferred technique to enhance the quality of blockade while minimising local anaesthetic doses. Intrathecal clonidine, as an adjuvant to local anaesthetics, enhances the quality and duration of spinal anaesthesia. However, the optimal dose remains controversial due to dosedependent side-effects. Aim: To compare the efficacy and safety of two different doses of intrathecal clonidine (30 μg vs 50 μg) as an adjuvant to hyperbaric levobupivacaine for spinal anaesthesia in femur fracture surgeries. Materials and Methods: This randomised triple-blind clinical study was conducted at the Department of Anaesthesiology at Shrimati Bhikhiben Kanjibhai Shah (SBKS) Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat, India, from January 2022 to December 2024 after institutional ethics committee approval. A total of 62 American Society of Anaesthesiologists (ASA) I-II patients aged 18- 65 years undergoing femur fracture surgeries were randomly allocated into two groups. Group LC30 (n=31) received 3 mL of 0.5% hyperbaric levobupivacaine with 30 μg clonidine and Group LC50 (n=31) received 3 mL of 0.5% hyperbaric levobupivacaine with 50 μg clonidine, both diluted to a total volume of 3.5 mL with normal saline. The onset and duration of sensory and motor blockade, along with the duration of absolute and effective analgesia, were assessed. Data analysis was performed using Jamovi software with independent t-tests for continuous variables and Chi-square tests for categorical variables. A p-value &lt;0.05 was considered statistically significant. Results: Demographic parameters, including age, gender, ASA grade and baseline haemodynamics, were comparable between the groups. No significant difference was observed in the onset of sensory or motor blockade between the two groups. The duration of sensory and motor blockade was longer in Group LC50 (263.30±9.2 and 359.20±18.1 min, respectively) compared to Group LC30 (215.78±7.7 and 300.27±10.6 min, respectively). The durations of absolute and effective analgesia were also longer in Group LC50 (300.50±18.2 and 451.70±18.2 min, respectively) compared to Group LC30 (289.90±11.9 and 315.10±37.6 min, respectively), with rescue analgesia required more frequently in the LC30 group. However, the LC50 group demonstrated a higher incidence of bradycardia (32.3% vs 12.9%), hypotension (45.2% vs 19.4%) and greater sedation compared to the LC30 group. Sedation scores were significantly higher in the LC50 group throughout the perioperative period. Conclusion: Intrathecal clonidine 50 μg combined with hyperbaric levobupivacaine provides significantly prolonged sensory and motor blockade with extended postoperative analgesia compared to a 30 μg dose. However, the higher dose is associated with an increased incidence of haemodynamic side-effects, necessitating closer monitoring and prompt intervention.

Category: Other Introduction/Purpose: Below the knee amputation (BKA) is an effective surgical procedure for individuals with severe injury or infection to their lower extremities. However, patients who receive these procedures are subject to significant morbidity and a high rate of postoperative complications due to the presence of multiple concomitant comorbidities. Despite the wide practice of this intervention, prognostic risk factors aiding in predicting surgical outcomes in these patients are poorly understood. The purpose of this study is to evaluate risk factors that may contribute to the outcomes of BKA procedures. Methods: The clinical and radiographic outcomes for 89 patients ages 19-90 who underwent BKA were retrospectively evaluated from 2012-2017. Postoperative complications of mortality, infection, and reoperation were evaluated with patient and surgical variables. Patient variables included: age, ambulatory status, obesity, diabetes, HbA1C2 levels, neuropathy, smoking, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) classification. Surgical variables evaluated included: presence of pre-op infection, pre-op ambulatory status, tourniquet time, tourniquet pressure, and usage of prophylactic antibiotics. Results: Of the patients evaluated there was an overall complication rate of 49% (44/89) and a mortality rate of 19% (17/89). Patients with diabetes (p=.035), a greater score on the Charlson Comorbidity Index (p=.001), and an ASA classification =3 (p=.005) were associated with a greater risk of mortality. Operative values (i.e. tourniquet time, tourniquet pressure etc.) did not affect patient mortality rates in a significant way, but there was a higher incidence of complications (i.e. mortality, post-op infections, and reoperations) with patients with pre-operative infections. Conclusion: Diabetes, a higher CCI score and a greater ASA value were found to be significant predictors of patient mortality after BKA (p&lt;0.05). Future perioperative optimization in these patients identified as high risk may improve patient outcomes in the future.

Study DesignRetrospective study.PurposeTo evaluate the factors affecting immediate postoperative mortality in elderly patients with tuberculous spondylodiscitis.Overview of LiteratureTreatment of spinal tuberculosis in the elderly involves consideration of age and co-morbidities, and often leads to an extended conservative management. Surgical intervention in these patients becomes a complex decision. There are no studies on risk factors of mortality in surgically treated elderly with tuberculous spondylodiscitis.MethodsTwo hundred and seventy-six patients with spondylodiscitis were operated between 2005 and 2015. 20 consecutive patients over 70 years of age with and proven tuberculosis who met the inclusion/exclusion criteria were included. Demographic, clinical and radiological profile data with operative details of instrumentation, blood loss, surgical duration, and mortality were noted. There were 20 patients (6 males, 14 females) with a mean age of 73.5 years. The patients were divided into those with mortality (M) and those who survived (non-mortality, NM). Various variables were statistically tested for immediate postoperative medical complications and mortality.ResultsThere were four mortalities (20%). Age, sex, number of medical co-morbidities, American Society of Anaesthesiologists grade, Frankel grade C or worse, number of vertebrae involved, number of levels fused, blood loss and operative time did not have statistically significant impact on immediate postoperative mortality. Only preoperative immobility duration was statistically higher in the M group (p=0.016) than in the NM group.ConclusionsPreoperative immobility is associated with immediate postoperative mortality in elderly patients with spinal tuberculosis undergoing surgery. The findings identify preoperative immobility as a risk factor for mortality, which could contribute to a more detailed prognostic discussion between surgeon and patient before surgery.

Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study

This study aimed to compare prosthetic alignment using three-dimensional (3D) measurements following total knee arthroplasty (TKA) performed using an accelerometer-based portable navigation system (KneeAlign2) versus the conventional technique. A total of 159 patients who had primary osteoarthritis of the knee with varus deformity underwent TKA. The KneeAlign2 system was used for distal femoral resection and tibial resection in 78 knees, and the conventional instrumentation (intramedullary for the femur and extramedullary for the tibia) was used in 81 knees. 3D computed tomography (CT) scans of the whole leg were taken after TKA. Femoral and tibial prosthetic alignments in the coronal, sagittal, and axial planes were measured using computer software. The operation time and estimated blood loss were calculated. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were evaluated using the contrast-enhanced multi-detector row CT at 1 week after TKA. In the femoral coronal plane, the mean and standard deviation of prosthetic alignment from neutral alignment were 1.2° [95% confidence interval (CI) 1.0°-1.4°) in the navigation group and 1.6° (95% CI 1.3°-2.0°) in the conventional group (p = 0.03). The femoral component outliers (> 3° away from the goal alignment) using the navigation system and the conventional technique were 3 and 15%, respectively, in the coronal plane (p < 0.01), and 15 and 43%, respectively, in the sagittal plane (p < 0.01). The outliers in tibial coronal and tibial sagittal planes were not statistically different between the two groups. There were no statistically significant differences between the two groups in operation time, blood loss, DVT, and PE. Using an accelerometer-based portable navigation system decreased the outliers of prosthetic alignment in femoral coronal and sagittal planes, and did not increase the complications such as operation time, blood loss, DVT, and PE. To our knowledge, this study is the first to investigate the usefulness of an accelerometer-based portable navigation system using the validated 3D measurement. III.

BackgroundAdolescent idiopathic scoliosis (AIS) surgery usually require prolonged operative times with extensive soft tissue dissection and significant perioperative blood loss, and allogeneic blood products are frequently needed. Methods to reduce the requirement for transfusion would have a beneficial effect on these patients. Although many previous studies have revealed the efficacy of tranexamic acid (TXA) in spinal surgery, there is still a lack of agreement concerning the reduction of both blood loss and transfusion requirements of large dose tranexamic acid (TXA) in surgery for adolescent idiopathic scoliosis (AIS). The objective of this study was to elevate the efficacy and safety of a large dose tranexamic acid (TXA) in reducing transfusion requirements of allogeneic blood products in adolescent idiopathic scoliosis (AIS) surgery using a retrospective study designed with historical control group.MethodsOne hundred thirty seven consecutive AIS patients who underwent surgery treatment with posterior spinal pedicle systems from August 2011 to March 2015 in our scoliosis center were retrospectively reviewed. Patients were divided into two groups, the TXA group and the historical recruited no TXA group (NTXA). Preoperative demographics, radiographic parameters, operative parameters, estimated blood loss (EBL), total irrigation fluid, number of patients requiring blood transfusion, mean drop of Hb (Pre-op Hb-Post-op Hb), haematocrit pre and post-surgery, mean volume of blood transfusion, hospitalization time, and adverse effect were recorded and compared.ResultsAll the patients were successfully treated with satisfied clinical and radiographic outcomes. There were 71 patients in the TXA group and 66 patients in the NTXA group. The preoperative demographics were homogeneity between two groups (P > 0.05). There were no significant difference in average operative time between two groups (209 min vs 215 min, p >0.05). Number of patients in the TXA group showed a significant decrease in transfusion requirements with an associated reduced intraoperative blood loss of nearly 45% compared with those in NTXA group (8 vs37, 619 ml vs 1125 ml, P < 0.05). There were no significant difference in total irrigation fluid between two groups (540 vs 550, p >0.05). Additional, patients in NTXA group showed significant decrease of Hb compared with patients in TXA group (5.2 g/dL vs 3.3 g/dL, P < 0.05), No significant difference were found in hospitalization time between two groups (6.3vs7.2 days, P > 0.05). No minor adverse effects associated with use of TXA were noted.ConclusionsUse of large dose tranexamic acid routinely seems to be effective and safe in reducing allogenic blood transfusion and blood loss in adolescent idiopathic scoliosis surgery.

Robotic-Assisted Total Knee Arthroplasty in Obese Patients

Excessive bleeding is one of the major threats to women at childbirth. The aim of this study was to validate estimation of blood loss during delivery. Bleeding was estimated after 29 elective cesarean sections and 26 vaginal deliveries and compared to blood loss measured by extraction of hemoglobin using the alkaline hematin method, according to Newton. Inter-individual agreement of estimation showed good results. Estimated loss in comparison with measured loss resulted in an over-estimation. In vaginally delivered women, there was no correlation between estimated and measured blood loss (r2=0.13), and in women delivered by elective cesarean section, the correlation was moderate (r2=0.55). Agreement, according to Bland and Altman, indicated that measured blood loss could vary from 570 ml less to 342 ml more than estimated blood loss. The standard procedure of estimation of obstetric bleeding was found to be unreliable. In this study, blood loss was over-estimated in cesareans. In vaginal deliveries, there seemed to be no correlation. Estimated blood loss as a quality indicator or as a variable in studies comparing complications must be used with caution. For clinical purposes, estimation of blood loss and measurement of post partum hemoglobin is of low value and may lead to the wrong conclusions.