RESUMEN
BACKGROUND: A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. METHODS: Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. RESULTS: Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. CONCLUSION: The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.
Asunto(s)
Artroplastia de Reemplazo de Cadera/normas , Artroplastia de Reemplazo de Rodilla/normas , Consenso , Técnica Delphi , Personal de Salud/normas , Atención Perioperativa/normas , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Rodilla/métodos , Humanos , Atención Perioperativa/métodos , Sudáfrica/epidemiologíaRESUMEN
Wear testing of total joint replacement (TJR) is mandatory in preclinical testing before implantation of TJR into the human body. Testing is governed by current international standards that recommend bovine serum (BS) as a lubricating fluid to replace synovial fluid (SF). Recently, the use of BS has been criticized because of differences in content, fluid characteristics, and nonhuman origin. As a result, a more realistic lubricant mimicking SF is needed. To define SF composition, we analyzed SF obtained during revisions of total hip and knee arthroplasties and compared it with SF obtained during primary arthroplasties and from patients without TJR. Samples were acquired from 152 patients. We found that the median total protein concentration for all SF was 36.8 mg/mL, which is significantly higher than concentrations currently recommended by the ISO standards. The γ-globulin concentration was significantly higher and the phospholipid concentration significantly lower in patients with revision of TJR compared with patients without TJR. No significant difference was found in hyaluronic acid concentration and viscosity among the groups. Our results support the need to improve the definition of a more clinically relevant wear testing lubricant in the ISO standards. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1422-1431, 2017.
Asunto(s)
Materiales Biomiméticos/química , Lubricantes/química , Fosfolípidos/análisis , Líquido Sinovial/química , gamma-Globinas/análisis , Adulto , Anciano , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fosfolípidos/metabolismo , Líquido Sinovial/metabolismo , gamma-Globinas/metabolismoRESUMEN
The lack of individualised care in orthopaedic regimes is often explained by the extended use of patient pathways and clinical guidelines. The aim of this study was to illuminate orthopaedic nurses' perceptions and experiences of providing individual nursing care for older patients in standardised fast-track programmes after total hip or knee replacement. Ten semi-structured interviews were conducted with orthopaedic nurses in orthopaedic wards at three Danish hospitals between April and June of 2015. Data were analysed using manifest and latent content analysis according to Graneheim and Lundman. The main theme of the overall interpretation was Orchestrating care through the fast-track perspective, accompanied by three sub-themes: Identifying and legitimising relevant individual care in the fast-track programme, Struggling to fit all patients in the fast-track programme and Justifying individualised care-related actions in the fast-track programme. The study concluded that, even though the nurses struggled to comply with the programme, they still found themselves compromising their nursing care and ethics to follow the standardised regime. There is a need to establish more specific inclusion criteria to maintain the effective elements in the programme and to facilitate nurses' opportunities to offer individual care, thereby ensuring that fragile patients have access to other possibilities.