RESUMEN
BACKGROUND: Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. METHOD: A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. RESULTS: Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. CONCLUSION: Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Ambulación Precoz , Humanos , Tiempo de Internación , Complicaciones Posoperatorias , Mejoramiento de la Calidad , Calidad de VidaRESUMEN
A quasi-experimental field study was undertaken to examine whether the source credibility of point-of-decision (POD) prompts would affect their effectiveness in increasing stair use. POD prompts attributed either to a more credible source, a less credible source, or nothing were randomly installed in three student halls of residence at a public university in Hong Kong (plus a control). The stair and elevator use of residents were recorded by view-from-top surveillance cameras and counted using motion-detection software, resulting in 14,189 observations. The findings show that all the POD prompts can yield, as hypothesized, a significant positive effect on stair use. The relative increase in stair use was 2.49% on average. However, contrary to our second hypothesis, the POD prompt attributed to the more credible source was not the most effective intervention. The implications of these findings are discussed in conclusion.
Asunto(s)
Promoción de la Salud/métodos , Subida de Escaleras , Toma de Decisiones , Femenino , Humanos , Masculino , Distribución Aleatoria , Confianza , UniversidadesRESUMEN
INTRODUCTION: Soft tissue imbalance is considered to be a major surgical cause of dissatisfaction following total knee arthroplasty (TKA). Surgeon-determined manual assessment of ligament tension has been shown to be a poor determinant of the true knee balance state. The recent introduction of intraoperative sensors, however, allows surgeons to precisely quantify knee compartment pressures and tibiofemoral kinematics, thereby optimising coronal and sagittal plane soft tissue balance. The primary hypothesis of this study is that achieving knee balance with use of sensors in TKA will improve patient-reported outcomes when compared with manual balancing. METHODS AND ANALYSIS: A multicentred, randomised controlled trial will compare patient-reported outcomes in 222 patients undergoing TKA using sensor-guided balancing versus manual balancing. The sensor will be used in both arms for purposes of data collection; however, surgeons will be blinded to the pressure data in patients randomised to manual balancing. The primary outcome will be the change from baseline to 1 year postoperatively in the mean of the four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS4) that are most specific to TKA recovery: pain, symptoms, function and knee-related quality of life. Secondary outcomes will include the surgeon's capacity to determine knee balance, radiographic and functional measures and additional patient-reported outcomes. Normality of data will be assessed, and a Student's t-test and equivalent non-parametric tests will be used to compare differences in means among the two groups. ETHICS AND DISSEMINATION: Ethics approval was obtained from South Eastern Sydney Local Health District, Approval (HREC/18/POWH/320). Results of the trial will be presented at orthopaedic surgical meetings and submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ACTRN#12618000817246.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/métodos , Articulación de la Rodilla , Monitoreo Intraoperatorio/métodos , Anciano , Fenómenos Biomecánicos , Femenino , Humanos , Articulación de la Rodilla/fisiopatología , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/cirugía , Equilibrio Postural/fisiología , Presión , Calidad de Vida , Rango del Movimiento Articular , Caminata/fisiologíaRESUMEN
OBJECTIVES: The aim of the study was to investigate how superior entry point varies with tibial rotation and to identify landmarks that can be used to identify suitable radiographs for successful intramedullary nail insertion. METHODS: The proximal tibia and knee were imaged for 12 cadaveric limbs undergoing 5° increments of internal and external rotation. Medial and lateral arthrotomies were performed, the ideal superior entry point was identified, and a 2-mm Kirschner wire inserted. A second Kirschner wire was sequentially placed at the 5-mm and then the 10-mm position, both medial and lateral to the initial Kirschner wire. Radiographs of the knee were obtained for all increments. The changing position of the ideal nail insertion point was recorded. RESULTS: A 30° arc (range, 25°-40°) provided a suitable anteroposterior radiograph. On the neutral anteroposterior radiograph, the Kirschner wire was 54% ± 1.5% (range, 51-56%) from the medial edge of the tibial plateau. For every 5° of rotation, the Kirschner wire moved 3% of the plateau width. During external rotation, a misleading medial entry point was obtained. A fibular bisector line correlated with an entry point that was ideal or up to 5 mm lateral to this but never medial. The film that best showed the fibular bisector line was between 0° and 10° of internal rotation of the tibia. CONCLUSIONS: The fibula head bisector line can be used to avoid choosing external rotation views and, thus, avoid medial insertion points. The current results may help the surgeon prevent malalignment during intramedullary nailing in proximal tibial fractures.