An updated meta-analysis evaluating limb management after total knee arthroplasty-what is the optimal method?

Influence of Limb Position on Venous Blood Flow After Total Knee Arthroplasty: A Prospective Randomized Study

Previous studies have suggested a clinical advantage when placing the limb in flexion after total knee arthroplasty (TKA). We sought to measure venous flow compared with control values after TKA. Our hypothesis was that the knee flexed positioning would not adversely affect venous flow. Two cohorts were prospectively evaluated. First, volunteers were randomized to positions with the knee flexed to approximately 90° or placed in a fully extended (control) position. Venous flow velocity was measured in the femoral vein every 15 minutes for 2 hours. Subsequently, 32 patients were randomized to 1 of these 2 positions after TKA, and venous flow velocity was measured in both the operative and the contralateral limb. In the healthy volunteer cohort, mean venous flow velocity was significantly higher at all time points in the flexion group compared with the extended control group (P<.05). After TKA, mean flow velocity for an extended knee (control) was 28.5 cm/s. Mean flow velocity for the flexed knee, foot-dependent group was 47.2 cm/s (P=.036) and for the flexed knee, foot-elevated group was 30.4 cm/s (P=.618). Placing the limb in a flexed position after TKA is not detrimental to venous flow velocity and resulted in higher velocities relative to the extended position. Placing the limb at 90° flexion does not cause venous stasis and should not increase the risk of deep venous thrombosis. [Orthopedics. 2023;46(1):8-12.].

The Effect of Joint Line Elevation on In Vivo Knee Kinematics in Bicruciate Retaining Total Knee Arthroplasty

Prior studies have reported a negative effect on both clinical outcomes and patient-reported outcome measures (PROMS) following joint line elevation (JLE) in cruciate-retaining (CR) total knee arthroplasty (TKA) and posterior stabilized (PS) TKA designs. This experimental study was aimed to quantify the effect of JLE on in vivo knee kinematics in patients with bicruciate retaining (BCR) TKA during strenuous activities. Thirty unilateral BCR TKA patients were evaluated during single-leg deep lunge and sit-to-stand using a validated combined computer tomography and dual fluoroscopic imaging system. Correlation analysis was performed to quantify any correlations between JLE and in vivo kinematics, as well as PROMS. There was a significant negative correlation between JLE and maximum flexion angle during single-leg deep lunge (ρ = -0.34, p = 0.02), maximum varus joint angles during single-leg deep lunge (ρ = -0.37, p = 0.04), and sit-to-stand (ρ = -0.29, p = 0.05). There was a significant negative correlation between JLE and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (ρ = -0.39, p = 0.01) and knee disability and osteoarthritis outcome score physical function (KOOS-PS; ρ = -0.33, p = 0.03). The JLE that yields a significant loss in PROMS and maximum flexion angles were 2.6 and 2.3 mm, respectively. There was a linear negative correlation of JLE with both in vivo knee kinematics and PROMS, with changes in JLE of greater than 2.6 and 2.3 mm, leading to a clinically significant loss in PROMS and maximum flexion angles, respectively, suggesting an increased need to improve surgical precision to optimize patient outcomes following BCR TKA.

The Efficacy of Rehabilitation Nursing Interventions on Patients with Open Lower Limb Fractures

Objective

The study aims to analyze the efficacy of rehabilitation nursing interventions on patients with open lower limb fractures.

Methods

From June 2020, patients who received RNI (observation group) were included and compared with patients who received routine nursing interventions (control group). The efficacy of different nursing modes was compared with several indicators.

Results

One hundred patients were included in this study, 50 in each group. The baseline characteristics were not significantly different between the groups. Regarding the emotional scores, the Self-Rating Anxiety Scale (SAS) score (26.98 vs 43.47), and Distress Management Screening Measure (DMSM) score (8.01 vs 12.85) in the observation group were significantly lower than those in the control group, both P < 0.05. Regarding the postoperative related indexes, the postoperative pain score (10.13 vs 15.53), fracture healing time (6.32 vs 10.86 weeks), and postoperative complications rate (0 vs 12%) in the observation group were all significantly lower than those in the control group, all P < 0.05. Regarding the quality of life scores, the WHOQOL-100 score (94.12 vs 83.13) and PSQI score (6.43 vs 10.36) were both significantly better in the observation group, with both P < 0.05.

Conclusion

Patients with open lower limbs who received RNI can help patients reduce postoperative anxiety and stress, promote postoperative rehabilitation and improve their quality of life.

How Satisfied Are Patients and Surgeons with Telemedicine in Orthopaedic Care During the COVID-19 Pandemic? A Systematic Review and Meta-analysis

BACKGROUND

The coronavirus disease 2019 pandemic has resulted in a rapid pivot toward telemedicine owing to closure of in-person elective clinics and sustained efforts at physical distancing worldwide. Throughout this period, there has been revived enthusiasm for delivering and receiving orthopaedic care remotely. Unfortunately, rapidly published editorials and commentaries during the pandemic have not adequately conveyed findings of published randomized trials on this topic.

QUESTIONS/PURPOSES

In this systematic review and meta-analysis of randomized trials, we asked: (1) What are the levels of patient and surgeon satisfaction with the use of telemedicine as a tool for orthopaedic care delivery? (2) Are there differences in patient-reported outcomes between telemedicine visits and in-person visits? (3) What is the difference in time commitment between telemedicine and in-person visits?

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review with the primary objective to determine patient and surgeon satisfaction with telemedicine, and secondary objectives to determine differences in patient-reported outcomes and time commitment. We used combinations of search keywords and medical subject headings around the terms "telemedicine", "telehealth", and "virtual care" combined with "orthopaedic", "orthopaedic surgery" and "randomized." We searched three medical databases (MEDLINE, Embase, and the Cochrane Library) in duplicate and performed manual searches to identify randomized controlled trials evaluating the outcomes of telemedicine and in-person orthopaedic assessments. Trials that studied an intervention that was considered to be telemedicine (that is, any form of remote or virtual care including, but not limited to, video, telephone, or internet-based care), had a control group that comprised in-person assessments performed by orthopaedic surgeons, and were reports of Level I original evidence were included in this study. Studies evaluating physiotherapy or rehabilitation interventions were excluded. Data was extracted by two reviewers and quantitative and qualitive summaries of results were generated. Methodological quality of included trials was assessed using the Cochrane Risk of Bias tool, which uniformly rated the trials at high risk of bias within the blinding categories (blinding of providers, patients, and outcome assessors). We screened 133 published articles; 12 articles (representing eight randomized controlled trials) met the inclusion criteria. There were 1008 patients randomized (511 to telemedicine groups and 497 to control groups). Subspecialties represented were hip and knee arthroplasty (two trials), upper extremity (two trials), pediatric trauma (one trial), adult trauma (one trial), and general orthopaedics (two trials).

RESULTS

There was no difference in the odds of satisfaction between patients receiving telemedicine care and those receiving in-person care (pooled odds ratio 0.89 [95% CI 0.40 to 1.99]; p = 0.79). There were also no differences in surgeon satisfaction (pooled OR 0.38 [95% CI 0.07 to 2.19]; p = 0.28) or among multiple patient-reported outcome measures that evaluated pain and function. Patients reported time savings, both when travel time was excluded (17 minutes shorter [95% CI 2 to 32]; p = 0.03) and when it was included (180 minutes shorter [95% CI 78 to 281]; p < 0.001).

CONCLUSION

Evidence from heterogeneous randomized studies demonstrates that the use of telemedicine for orthopaedic assessments does not result in identifiable differences in patient or surgeon satisfaction compared with in-person assessments. Importantly, the source studies in this review did not adequately capture or report safety endpoints, such as complications or missed diagnoses. Future studies must be adequately powered to detect these differences to ensure patient safety is not compromised with the use of telemedicine. Although telemedicine may lead to a similar patient experience, surgeons should maintain a low threshold for follow-up with in-person assessments whenever possible in the absence of further safety data.

LEVEL OF EVIDENCE

Level I, therapeutic study.

[The influence of knee flexion position on postoperative blood loss and knee range of motion after total knee arthroplasty]

OBJECTIVE

To summarize research progress of the effect of knee flexion position on postoperative blood loss and knee range of motion (ROM) after total knee arthroplasty (TKA).

METHODS

The relevant literature at home and abroad was reviewed and summarized from mechanism, research status, progress, and clinical outcome. The differences of clinical results caused by different positions, flexion angles, and keeping time were compared.

RESULTS

Keeping knee flexion after TKA can reduce postoperative blood loss through the angle change of blood vessels and increase knee early ROM by improving flexion muscle strength. When the flexion angle of the knee is large and the flexion position is keeping for a long time, the postoperative blood loss and the knee ROM can be significantly improved. However, the amount of blood loss and ROM are not further improved in the patients with keeping knee flexion for more than 24 hours compared with less than 24 hours.

CONCLUSION

Keeping knee flexion after TKA is a simple and effective method to reduce postoperative blood loss and improve knee ROM. However, the optimal knee flexion angle and time are needed to be further explored.