Short-Term Outcomes of Enhanced Recovery after Surgery (ERAS) for Ankle Fracture Patients: A Single-Center Retrospective Cohort Study

Clinical practice guidelines for rehabilitation following surgical management of chronic lateral ankle instability: enhancing recovery based on available evidence

BACKGROUND

Rehabilitation is a crucial component of comprehensive disease management and functional recovery. Despite advancements in surgical techniques for chronic lateral ankle instability (CLAI), there is still a lack of standardized, evidence-based rehabilitation protocols.

SOURCE OF DATA

After nine clinical questions were proposed by the guidance steering group, an independent search strategy was conducted for all clinical questions, encompassing the PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

AREAS OF AGREEMENT

Rehabilitation is crucial to optimize surgical outcomes and patient recovery. An appropriate and well-structured rehabilitation plan can optimize a safe return to sports and daily activities.

AREAS OF CONTROVERSY

Rehabilitation for surgical management of CLAI poses significant challenges, especially in the areas of preoperative preparation, control of postoperative swelling and pain, early-stage rehabilitation, advanced rehabilitation, and return to exercise.

GROWING POINTS

Given the lack of established guidelines for rehabilitation following surgical management of CLAI, this clinical practice guideline presents nine key recommendations aimed at addressing the existing controversies in this area. For CLAI patients undergoing surgery, preoperative rehabilitation should include exercise and education, followed by postoperative focus on pain and swelling management. Early rehabilitation emphasizes nonweight-bearing functional training, with gradual progression to weight-bearing exercises, dynamic balance, and strength training over the first 18 weeks. Regular follow-up visits are essential to monitor recovery and promote functional restoration.

AREAS TIMELY FOR DEVELOPING RESEARCH

In patients undergoing surgery for CLAI, there is a pressing need for comparative studies to assess the necessity of immobilization and to determine the optimal selection of braces.

Implementability of opioid deprescribing interventions at transitions of care: A scoping review

Continuation of opioids at transitions of care increases the risk of long-term opioid use and related harm. To our knowledge, no study has examined the implementability of opioid deprescribing interventions at transitions of care. Our scoping review aimed to identify the type of opioid deprescribing interventions employed at transitions of care and assess the implementability of tested interventions. Nine electronic databases were searched on 15 May 2023 for English-language studies of adults transitioning between care settings, where opioid deprescribing interventions targeting patients, clinicians or health systems were implemented. Implementability was assessed using the Cochrane Intervention Complexity Assessment Tool for Systematic Reviews to determine intervention complexity, and mapped to the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to understand the process evaluation. A total of 79 studies were identified, with 94.0% (n = 74) examining hospital-to-home transitions. Mixed interventions (combination of pharmacological and nonpharmacological) were tested in 49.0% (n = 39) of studies. Pharmacological interventions were identified in 31.0% (n = 24) of studies, and the remaining 20.0% (n = 16) applied nonpharmacological interventions. Mixed interventions comprising multiple components were the most complex and resulted in reduced opioid use across transitions of care in 28.0% (n = 22) of studies. Few studies reported on RE-AIM dimensions including implementation (5.0% of studies), reach (4.0%), adoption (4.0%) and maintenance (0%). Most opioid deprescribing interventions targeted hospital to home care transition with mixed results in opioid deprescribing. Further research should consider the implementability of interventions during transitions of care to elucidate the impact of opioid deprescribing interventions across care settings.

The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates.

METHODS

The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively.

RESULTS

A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05).

CONCLUSION

The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.

Impact of ERAS compliance on the short-term outcomes for distal radius surgery: a single-center retrospective study

BACKGROUND

Distal radius fractures (DRF) account for one in five bony injuries in both primary and secondary trauma care. Enhanced recovery after surgery (ERAS) has been adopted successfully to improve clinical outcomes in multiple surgical disciplines; however, no study has investigated the effect of different degrees of compliance with ERAS protocol on short-term outcomes following distal radius surgery. We aimed to analyze whether different degrees of compliance with the ERAS pathway are associated with clinical improvement following surgery for DRF.

METHODS

We retrospectively analyzed all consecutive patients with ERAS who underwent surgery for DRF at our department between May 2019 and October 2022. Their pre-, peri-, and post-operative compliance with the 22 elements of the ERAS program were assessed. We compared parameters between low- (< 68.1%) and high-compliance (> 68.1%) groups, including patient complications, total length of hospitalization, discharge time after surgery, hospital costs, time taken to return to preinjury level performance level, number of visual analogue scale (VAS) pain scores > 3 points during hospitalization, disabilities of the arm, shoulder and hand (DASH) scores. We performed multiple linear regression analyses to assess the impact of ERAS compliance on the postoperative function level (DASH scores).

RESULTS

No significant differences were detected between the high- and low-compliance groups with respect to demographics, including sex, age, body mass index (BMI), and comorbidities (P > 0.05). We observed significant differences between the high- and low-compliance groups in terms of the DASH score (32.25 ± 9.97 vs. 40.50 ± 15.65, p < 0.05) at 6 months postoperatively, the discharge time after surgery (2.45 ± 1.46 vs. 3.14 ± 1.50, p < 0.05), and number of times when the VAS pain score was > 3 points during hospitalization (0.88, [0.44, 1.31], p < 0.05). Our study demonstrated a significant negative association between ERAS compliance and the function level of patients postoperatively (DASH scores) when adjusted for age, comorbidity, sex, and BMI.

CONCLUSIONS

This study provided a realistic evaluation and comparison of the ERAS protocol among patients with DRF and can guide clinical decision making. The ERAS protocol may improve outcomes after surgery, with high postoperative function levels and reduced pain and discharge time after surgery, without increased complication rates or hospital costs.