Fast-track knee arthroplasty – status and future challenges

BackgroundFast-track programs have been developed for different surgical procedures leading to higher patient satisfaction and lower morbidity. This concept has been extended to knee arthroplasty in recent years. The purpose of this narrative review was to discuss the different aspects of fast-track knee arthroplasty.MethodBoth authors searched the contemporary literature on minimally invasive knee arthroplasty and review articles on fast-track surgery aiming to summarize recent developments.ResultsLength of stay after knee arthroplasty is influenced by preoperative risk factors, anaesthetic and surgical techniques, pain, orthostatic intolerance, cognitive function, sleep disturbances, bleeding and anaemia and finally muscle function and rehabilitation.ConclusionsFast-track surgery reduces the length of stay and the morbidity after knee arthroplasty.Clinical relevanceOptimisation of pre-, per- and postoperative pathway for knee arthroplasty reduces morbidity after this type of surgery and results in shorter length of stay.     

Traumatic Experiences: Harbinger of Risk Behavior Among HIV-Positive Adults

SUMMARY

Far more than in the general population, people living with HIV tend to report experiencing traumatic life events, particularly those that are violent and abusive. The majority of AIDS cases in the United States and globally result from either unprotected sexual intercourse or the use of contaminated injection drug needles. This study examined the relationship between trauma history, trauma-related symptoms, and sexual risk behavior. The sample included 64 men and women living with HIV/AIDS. An examination of trauma symptoms and sexual risk behavior indicated that moderate to severe trauma symptoms were significantly correlated with unprotected sexual intercourse during the past three months. Moreover, reliving the traumatic event (i.e., experiencing flashbacks, having nightmares) was significantly and positively associated with having more partners in the past 3 months. Greater symptoms of intrusion and avoidance were associated with unprotected sex. After controlling for demographic factors, multiple regression analysis indicated that greater severity of sexual coercion, greater intrusion symptoms, and less avoidant symptoms were positively associated with greater sexual risk behavior. Thus, reducing trauma symptoms among adults with moderate to severe symptoms may be a particularly effective HIV-prevention intervention for adults living with HIV/AIDS.     

Posttraumatic intrusion, avoidance, and social functioning: a 20-year longitudinal study

The study assesses posttraumatic intrusion, avoidance, and social functioning among 214 Israeli combat veterans from the first Lebanon War with and without combat stress reaction (CSR) 1, 2, 3, and 20 years after the war. CSR veterans reported higher intrusion and avoidance than did non-CSR veterans. With time, there was a decline in these symptoms. In addition, intrusion and avoidance were associated with problems in social functioning on a given year, and they longitudinally predicted social dysfunction 2, 3, and 20 years after the war. CSR veterans presented stronger temporal covariations between intrusion-avoidance and social functioning. The findings suggest that CSR is a marker for future psychopathology and point to the role of avoidance in social dysfunction.     

Preoperative concerns of patients undergoing general surgery

ObjectivesThis qualitative review aims to provide a clearer understanding of concerns general surgery (GS) patients face in the preoperative period.MethodsMedline, CINAHL, PsycINFO and Web of Science were searched for articles describing the preoperative concerns of GS patients. Qualitative and mixed method studies were included. Key quotes were extracted, coded, and thematically analyzed according to Thomas and Harden’s methodology.Results27 articles were included. Three main themes were generated: (1) lead-up to surgery, (2) postoperative recovery process and (3) standard of care. While waiting for surgery, patients were often shrouded with uncertainty and concerned themselves with the potential impacts of their disease and surgery on their wellbeing and recovery. Furthermore, patients’ trust and confidence in Healthcare Professionals (HCPs) was compromised when standard of care was perceived to be deficient, resulting in doubts about HCPs’ credibility and capabilities.ConclusionPatients’ preoperative concerns often stem from the uncertainty and unfamiliarity surrounding surgery. To address this, a combination of effective preoperative education, individualised communication and involvement of social support should be considered.Practice implicationsPreoperative concerns can negatively impact patients and effective interventions will result in a better perioperative experience with fewer negative consequences arising from patients’ fear and anxiety.     

Medial closing-wedge distal femoral varus osteotomy: Symptoms and functional impact in cases of associated patellofemoral osteoarthritis. A two-year follow-up prospective pilot study

PurposeTo date, indications for distal femoral varus osteotomy (FVO) in cases of associated patellofemoral osteoarthritis (PFO) have yet to be clarified. The purpose of this prospective study is to assess the short-term symptoms, functional and radiological impact of a medial closing-wedge femoral varus osteotomy on the patellofemoral joint in patients with valgus deformities who are afflicted with lateral tibiofemoral osteoarthritis (LTFO) associated with PFO.MethodsFourteen patients (15 knees) received a medial closing-wedge femoral varus osteotomy. The functional impact of an FVO on the patellofemoral joint was assessed based on the KOOS-PF (Knee Injury and Osteoarthritis Outcome Score-Patellofemoral Subscale), the Kujala score and the patellofemoral symptoms. Realignment of the patella was measured by the Merchant's patellofemoral congruence angle. The pre- and post-operative symptoms and functional scores were compiled prospectively and compared two years after the surgery.ResultsThe Kujala patellofemoral functional scores and the KOOS-PF showed considerable improvement with a differential of + 37.5 points ± 20.4 and + 42.7 points ± 19.3 (p < .01) respectively. The average Merchant's congruence angle went from 8.8° laterally to 3.6° medially, resulting in medialization of the patella, with a significant difference (p < .01). Based on the specific clinical analysis of the patellar joint, preoperative J-sign was identified in 26.7% of patients (n = 4) and was not found during postoperative examination (p = .1). Preoperative apprehension test was identified in 33.3% of patients (n = 5) against 13.3% (n = 2) after surgery (p = .39). Preoperative pain extension test was identified in 40% of patients (n = 6) against 20% during postoperative clinical analysis (p = .43).DiscussionAlthough the threshold of significance for patellofemoral symptoms was not reached, the medial closing-wedge femoral varus osteotomy induces a significant medialization of the patella (Merchant's congruence angle) and improves short-term functional results even with co-existing patellofemoral osteoarthritis. Due to the lack of specificity of the patellofemoral scores, patellofemoral osteoarthritis improvement is difficult to determine on its own, but does not represent a contraindication to FVO.Level of evidenceIII. Prospective clinical study.     

Partial resection of lateral discoid meniscus changes lower limb axial alignment – A retrospective cohort study

AimThis study aimed to explore the changes in lower limb axial alignment and knee joint function after arthroscopic partial resection of the discoid lateral meniscus.MethodsPreoperative and postoperative full-length weight-bearing radiographs of the lower limb were obtained from a total of 161 patients with lateral menisci tears from September 2018 to September 2020 who underwent partial meniscal resection. The patients were divided into discoid meniscus group (DMG) and ordinary meniscus group (OMG). The measured mechanical axis deviation (MAD), proximal tibia angle (PTA), and distal femoral angle (DFA) in the axial alignment of the lower limb were determined before and after surgery. Knee joint function on the affected side was determined using the International Knee Documentation Committee (IKDC) subjective scale and the Lysholm knee scoring scale before surgery and at one, six, 12, and 24 months after surgery.ResultsFor MAD and DFA, there were statistically significant differences between the preoperative and postoperative findings within each group (P < 0.01); the MAD and DFA were smaller after surgery. The difference in preoperative and postoperative PTA of the DMG was statistically significant (P < 0.01), meaning that the PTA becomes larger after surgery. The differences in preoperative and postoperative PTA of the OMG, preoperative PTA between the two groups, and postoperative PTA between the two groups were not statistically significant (P > 0.05). Intragroup comparisons of the IKDC subjective scale and the Lysholm knee scoring scale before and after surgery revealed significant differences (P < 0.05).ConclusionArthroscopic partial resection of the discoid lateral meniscus is a safe and effective surgical method that can significantly improve knee joint function. Although the axial arrangement of the lower limbs will be slightly changed in the early stage, it will still be within the normal range after surgery in patients with normal lower limb axial alignment. For patients with varus or valgus before surgery, this procedure should be applied with caution.     

Psychosocial buffers of traumatic stress,depressive symptoms,and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: The role of resilience,unit support,and postdeployment social support

BackgroundLittle research has examined the role of protective factors such as psychological resilience, unit support, and postdeployment social support in buffering against PTSD and depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF).Materials and methodsA total of 272 OEF/OIF veterans completed a survey containing PTSD and depression screening measures, and questionnaires assessing resilience, social support, and psychosocial functioning.ResultsLower unit support and postdeployment social support were associated with increased PTSD and depressive symptoms, and decreased resilience and psychosocial functioning. Path analyses suggested that resilience fully mediated the association between unit support and PTSD and depressive symptoms, and that postdeployment social support partially mediated the association between PTSD and depressive symptoms and psychosocial functioning.LimitationsGeneralizability of results is limited by the relatively low response rate and predominantly older and reserve/National Guard sample.ConclusionsThese results suggest that interventions designed to bolster unit support, resilience, and postdeployment support may help protect against traumatic stress and depressive symptoms, and improve psychosocial functioning in veterans.     

创伤后应激障碍的临床研究新进展(DSM-5新标准)

创伤后应激障碍(PTSD)是一种严重的心理障碍。PTSD常在一个人暴露于一个或多个创伤性事件后产生,如重大的刺激、性侵犯、恐怖事件或对一个人生活其他严重威胁。主要症状包括令人不安重复闪回,对事件的回避或记忆麻木,警觉性增高等。PTSD的诊断是在创伤性事件发生后持续1个月以上。美国精神病学会在2013年5月出版了《精神疾病诊断与统计手册》第5版(DSM-5)。DSM-5将PTSD的核心症状修改为4组:1在创伤事件发生后,存在1种(或多种)与创伤事件有关的重新体验症状;2创伤事件后开始持续地回避与创伤事件有关的刺激;3与创伤性事件有关的认知和心境方面的消极改变,在创伤事件发生后开始出现或加重;4与创伤事件有关的警觉性或反应性有显著的改变,在创伤事件发生后开始或加重。近年来,对PTSD的临床研究成为精神病学、心身医学和临床心理学的热点。根据DSM-5的标准和新的临床研究成果,本文对PTSD的病因和发病机制、临床表现、诊断标准、诊断和鉴别诊断、治疗、预防和预后进行了分析。     

Effects of preoperative individualized audiovisual education on anxiety and comfort in patients undergoing laparoscopic cholecystectomy: randomised controlled study

ObjectiveThe study aimed to determine the effects of preoperative individualized audiovisual education for laparoscopic cholecystectomy patients on postoperative anxiety and comfort (pain, nausea, and vomiting).MethodThis study was a randomized clinical trial on 124 patients undergoing laparoscopic cholecystectomy. Patients were randomized into an intervention group (individualized audiovisual education) or a control group (standard education). The primary outcome was change in anxiety and comfort levels between the intervention and control groups at baseline and follow-up. Secondary outcomes were change between groups in Patient Learning Needs Scale scores and vital signs.ResultsAlthough the preoperative visual analog scale (VAS)-pain and VAS-nausea scores of the patients in both groups were similar, the postoperative VAS-pain and VAS-nausea levels of the intervention group were significantly lower than that of the control group (p < 0.05). The anxiety levels of the intervention group were also lower both before (42.79 ± 4.29) and after (39.08 ± 3.49) surgery than that of the control group (50.98 ± 5.45 and 44.41 ± 4.77, respectively).ConclusionThis study showed that preoperative individualized audiovisual education was effective in reducing anxiety and improving patient comfort.Practice implicationsPreoperative individualized audiovisual education is crucial for clinical care and can be integrated into other patients because of its positive effects on postoperative recovery outcomes.     

Risk factors for ventilator dependency following coronary artery bypass grafting

Background: Ventilator dependency following coronary artery bypass grafting (CABG) is often associated with significant morbidity and mortality. However, few reports have focused on the independent risk factors for ventilator dependency following CABG. This study aimed to evaluate the independent risk factors for ventilator dependency following coronary artery bypass grafting (CABG). Methods: The relevant pre-, intra- and post-operative data of patients without a history of chronic obstructive pulmonary disease undergoing isolated CABG from January 2003 to December 2008 in our center were retrospectively analyzed. Elapsed time between CABG and extubation of more than 48 hours was defined as postoperative ventilator dependency (PVD). Results: The incidence of PVD was 13.8% (81/588). The in-hospital mortality in the PVD group was significantly higher than that in the non-PVD group (8.6% versus 2.4%, p=0.0092). Besides the length of ICU and hospital stay, PVD correlated with negative respiratory outcomes. The independent risk factors for PVD were preoperative congestive heart failure (OR=2.456, 95%CI 1.426-6.879), preoperative hypoalbuminemia (OR=1.353, 95%CI 1.125-3.232), preoperative arterial oxygen partial pressure (PO₂) (OR=0.462, 95%CI 0.235-0.783) and postoperative anaemia (OR=1.541, 95%CI 1.231-3.783). Conclusions: Preoperative congestive heart failure, preoperative hypoalbuminemia, low preoperative PO₂ and postoperative anaemia were identified as four independent risk factors for ventilator dependency following CABG.     

Clinical presentation and outcomes of cholecystectomy for acute cholecystitis in patients with diabetes - A matched pair analysis. A pilot study

PurposeThe primary aim of this study is to compare the clinical course and laboratory parameters of acute cholecystitis in patients with diabetes vs. patients without diabetes.Materials and methodsThe study involved patients who underwent emergency cholecystectomy in the Department of General, Endocrine and Transplant Surgery of University Clinical Center in Gdansk (Poland) between 2007 and 2017.There were 267 patients included in the study. The control group of 197 patients was age and sex matched at a 3:1 ratio.The following was compared between the groups: symptoms at admission, course of surgery, postoperative course, length of hospitalization, total costs of hospitalization and antibiotic therapy, other than routine perioperative prophylaxis.ResultsThere was no significant difference between the patients with and without diabetes regarding symptoms at admission. Operative and postoperative complication rates were significantly higher in the patients with diabetes. The operative time and length of hospitalization were significantly longer in the study group. The conversion rate was not higher in the study group, but classic surgery was performed significantly more often. The patients without diabetes had less pronounced symptoms with more locally advanced disease.ConclusionsOur study demonstrates that patients with diabetes have a significantly more eventful course of acute cholecystitis than patients without diabetes. Patients with diabetes should therefore be qualified for cholecystectomy early in the course of acute cholecystitis.     

Surgical site infection with extended-spectrum β-lactamase-producing Enterobacteriaceae after cardiac surgery: incidence and risk factors

ObjectiveTo determine the incidence, microbiology and risk factors for sternal wound infection (SWI) with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) following cardiac surgery.MethodsWe performed a retrospective analysis between January 2006 and December 2015 of prospective surveillance of a cohort of patients with cardiac surgery at a single centre (Paris, France). SWI was defined as the need for reoperation due to sternal infection. All patients with an initial surgery under extracorporeal circulation and diagnosed with an SWI caused by Enterobacteriaceae isolates were included. We compared patients infected with at least one ESBL-PE with those with SWI due to other Enterobacteriaceae by logistic regression analysis.ResultsOf the 11 167 patients who underwent cardiac surgery, 412 (3.7%) developed SWI, among which Enterobacteriaceae were isolated in 150 patients (36.5%), including 29 ESBL-PE. The main Enterobacteriaceae (n = 171) were Escherichia coli in 49 patients (29%) and Enterobacter cloacae in 26 (15%). Risk factors for SWI with ESBL-PE in the multivariate logistic regression were previous intensive care unit admission during the preceding 6 months (adjusted odds ratio (aOR) 12.2; 95% CI 3.3–44.8), postoperative intensive care unit stay before surgery for SWI longer than 5 days (aOR 4.6; 95% CI 1.7–11.9) and being born outside France (aOR 3.2; 95% CI 1.2–8.3).ConclusionsOur results suggest that SWI due to ESBL-PE was associated with preoperative and postoperative unstable state, requiring an intensive care unit stay longer than the usual 24 or 48 postoperative hours, whereas being born outside France may indicate ESBL-PE carriage before hospital admission.     

虚拟仿真手术与常规手术对肾结石治疗效果的比较

目的 重建肾脏的三维立体模型,模拟经皮肾镜碎石术在虚拟仿真手术和常规手术的效果.为临床教学和科研提供方法,为年轻医生快速缩短手术学习时间.方法 随机选取2017年12月～2019年2月北京房山区良乡医院就诊的30例肾结石患者作为试验组,对照组是同期在该院进行体检的正常人30例.两组采集肾脏CT扫描数据,利用Mimics...     

慢重症患者的反刍思维水平及其影响因素研究

目的：调查慢重症(chronically critical ill，CCI)患者的反刍思维水平及探讨其相关影响因素。方法：采用一般人口学资料调查表、反刍思维量表(ruminative responses scale，RRS)对佛山市某综合医院符合入选标准的97名慢重症患者进行调查。结果：慢重症患者的反刍思维总得分为(65.96±16.40)分，总分及各因子得分均明显高于国内常模(P<0.05)；多元线性回归结果显示， ICU住院时间、辅助通气情况、生活自理能力、医疗费用负担能力以及社会支持情况是慢重症患者反刍思维的影响因素(P<0.05)，共可解释方差变异量的36.5%。结论：慢重症患者的反刍思维处于较高水平，护理人员在实施治疗工作时应加强对患者的有效评估，并根据患者的具体情况从不同角度有针对性地实施护理干预，以纠正患者的负性思维方式，提高患者对疾病的适应水平和心理健康。     

Relationships between self‐consistency,trauma‐centred identity,and post‐traumatic adjustment

Background: Post‐traumatic stress disorder (PTSD) models suggest that trauma‐centred self‐change is motivated by self‐consistency. Aim: The objective of this study was to investigate the relationships between self‐consistency, trauma‐centred identity, and PTSD symptoms. Method: University students (n = 134) completed measures of trauma‐centred identity (Centrality of Events Scale), self‐consistency, and post‐traumatic stress symptoms (Impact of Events Scale—Revised, Centre for Epidemiological Studies—Depression Scale). Results: A significant positive correlation was found between trauma‐centred identity and post‐traumatic symptoms. However, self‐consistency was not related to post‐traumatic symptoms or trauma‐centred identity. Given the relationship between depressive symptoms and self‐consistency, the correlations were also conducted controlling for depression. When the effects of depressive symptoms were partialled out, both self‐consistency and trauma‐centred identity were positively correlated with intrusion symptoms. Discussion and Conclusion: The implications for PTSD models, which suggest self‐change is motivated by self‐consistency, are discussed and implications for clinical treatments are considered.     

天玑骨科机器人Tirobot导航系统在骨盆骨折手术中的应用

目的 观察天玑骨科机器人Tirobot导航系统在骨盆骨折手术中的临床应用疗效,探讨其临床应用价值。方法 搜集2021年9月至2022年9月于中国科学技术大学附属第一医院（安徽省立医院）创伤骨科使用天玑机器人Tirobot导航系统辅助行骨盆骨折手术治疗的患者资料。入院时评估创伤严重性评分（ISS）,记录患者的术前等待时间、住院时间、手术时间、术中出血量、术中透视次数、术后负重时间,术后末次随访采用Majeed评分评估骨盆功能。结果 所有患者术后均获得有效随访,平均随访时间（6.9±3.7）个月（2 ～ 12个月）。其中10例患者术前由重症医学科（ICU）转入创伤骨科行手术治疗。所有患者术前等待时间为（7.4±4.2）d,住院时间为（14.7±10.9）d,手术时间为（191.1±39.4） min,出血量中位数为100 mL（5 ～ 1 000 mL）,平均透视次数为21.7次（17 ～ 31）次。术后患者负重时间中位数为8（4 ～ 20）周。末次随访根据Majeed评分,其中优19例,良6例,可3例,差6例,优良率为73.5%。结论 天玑机器人Tirobot导航系统在骨盆骨折微创治疗手术中可以提高内植物置入精准性,提升手术效率,减轻患者病痛,减少辐射,具有较高的临床应用前景。     

Psychological Preparation as a Method of Reducing the Stress of Surgery

Abstract

Studies of the preparation of adult patients for surgery are reviewed. While many show that preparation reduces stress, the studies are criticized for methodological and conceptual inadequacies. In particular, studies often fail to measure a range of stress responses, and also fail to provide measures over a sufficient time span to fully assess the effect of preparation on stress responses which are known to have differing rates of responsiveness. The experimental study was specifically designed to overcome these problems. Eighty patients undergoing a minor gynecological operation (laparoscopy for sterilization or infertility investigation) were allocated to one of three groups: routine care only (Control 1); routine care plus a minimally informative preparatory booklet (Control 2); or routine care plus a maximally informative preparatory booklet (Experimental group). Patients in the special preparation condition showed lower stress responses on measures of preoperative fear and anxiety, heart rate and blood pressure, and postoperative anxiety. At both one-and six-week follow ups they showed reduced state anxiety and elevated postdischarge vigor scores. They also showed less pain after surgery and recovered faster in hospital and in the first six days after going home. They returned to normal activities faster than patients in the two control groups. There were no differences on measures of postoperative symptoms, medication use, or reported time to return to normal health. The results are discussed in terms of previous studies of psychological preparation, and current concepts of stress. Suggestions for the design of preparatory interventions are made which match the type and timing of the intervention to the target stress response.     

Impact of frailty and ultrasonography-based sarcopenia on the development of postoperative complications in gastrointestinal cancer patients

Background/aim Gastrointestinal (GI) system cancers are frequent among older adults and it is still difficult to predict which are at increased risk for postoperative complications. Frailty and sarcopenia are increasing problems of older population and may be associated with adverse outcomes. In this study we aimed to examine the effect of sarcopenia and frailty on postoperative complications in older patients undergoing surgery for GI cancers.Materials and methods Forty-nine patients admitted to general surgery clinic with the diagnosis of gastrointestinal system cancers were included in this cross-sectional study. Frailty status was assessed using the Edmonton Frail Scale (EFS). Sarcopenia was defined due to the EWGSOP2 criteria and ultrasonography was used to evaluate muscle mass.Results The median age of the patients was 70 (min-max: 65–87). Fourteen (28.6%) patients were found to be sarcopenic and 16 (32.7%) patients were frail, and 6 (37.5%) of these patients were also severe sarcopenic (p = 0.04). When the postoperative complications were assessed, time to oral intake, time to enough oral intake, length of hospital stay in the postoperative period were found to be longer in frail patients (p = 0.02, p = 0.03, p = 0.04 respectively). Postoperative complications were not different due to the sarcopenia.Conclusion Frailty, but not sarcopenia was associated with adverse outcomes in older adults undergoing GI cancer surgery. Comprehensive geriatric assessment before surgical intervention may help to identify patients who are at risk.     

Fulfilment of preoperative expectations and postoperative patient satisfaction after total knee replacement. A prospective analysis of 200 patients

BackgroundIn total knee arthroplasty (TKA), the association between preoperative patient expectations, their postoperative fulfilment, and satisfaction is not well understood. The aim of this study was to quantify these relationships in a cohort of TKA patients with differing socio-economic backgrounds from across Scotland.MethodsExpectations of 200 patients undergoing TKA were assessed using the Hospital for Special Surgery Knee Replacement Expectation Score. Postoperatively, expectation fulfilment was assessed at six weeks and one year. Satisfaction was measured using a five-point Likert scale. Preoperative and postoperative scores were compared across satisfaction groups. Relationships between individual and overall expectation fulfilment, satisfaction, and demographics were analysed.ResultsAt six weeks, 30% of expectations were fulfilled, increasing to 48% at one year. Corresponding satisfaction rates were 84% and 89%. Higher fulfilment scores were associated with greater satisfaction. Fulfilment of pain and mobility expectations were most predictive of satisfaction. Expectations of kneeling, squatting, paid work and sexual function went unfulfilled. Preoperative expectations were not related to postoperative satisfaction. Males had higher postoperative fulfilment scores.ConclusionsThis study showed a clear association between fulfilment of preoperative expectations and patient satisfaction following TKA. However, less than 50% of patient expectations were completely fulfilled. While higher fulfilment scores were predictive of greater satisfaction, low overall fulfilment score did not preclude satisfaction. The high correlation of pain and function expectation fulfilment with satisfaction emphasises the need to relate these as appropriate preoperative expectations, while awareness of unfulfilled expectations may allow engagement with and resolution of ongoing concerns and disappointments.