Recognising and dealing with complications in orthopaedic surgery

Complications in Total Ankle Replacement

The debate between ankle arthrodesis and total ankle replacement for patients with end-stage arthritis of the ankle joint is an ongoing topic in orthopedic surgery. Ankle arthrodesis, or fusion, has been the traditional treatment for ankle arthritis. It involves fusing the bones of the ankle joint together, eliminating the joint and creating a solid bony union. Arthrodesis is effective in reducing pain in the ankle, but it results in a loss of ankle motion. This can increase the load on adjacent joints, such as the subtalar joint, which may lead to accelerated degeneration and arthritis in those joints over time.

Systemic medical complications following joint replacement: a review of the evidence

INTRODUCTION

Arthroplasty procedures are commonly performed in the UK. Informed consent is required for each procedure. To obtain informed consent the patient and their surgeon should discuss the risks and benefits of the proposed operation. This discussion should include both regional and systemic complication rates. Regional complications of arthroplasty are generally well documented in the literature. Systemic medical complications are less well described. This lack of accurate data could make it difficult for the treating surgeon to obtain valid consent. The aim of this paper was to review and compare the literature regarding the rate of systemic medical complications after common arthroplasty procedures.

METHODS

A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Studies regarding the systemic medical complications and mortality rate of joint replacement were included.

FINDINGS

We found that systemic complications were more frequent than regional complications following arthroplasty. The systemic complication rates were: hip, 5.1%; knee, 6.9%; ankle, 3.0%; shoulder, 11.2%; elbow, 8.5%; and wrist, 0%. Mortality rates for arthroplasty procedures were: hip, 0.3%; knee, 0.2%; ankle, 0.3%; shoulder, 0.3%; elbow, 0.2%; and wrist, 0%.

CONCLUSIONS

The most common systemic medical complication following arthroplasty was venous thromboembolism. Preoperative comorbidity was the most important risk factor for both postoperative mortality and systemic medical complications following arthroplasty procedures. We recommend that to obtain informed consent the given rates of systemic medical complications of joint replacement should be discussed and documented.

Complications following total ankle arthroplasty: A systematic literature review and meta-analysis

BACKGROUND

Total ankle arthroplasty (TAA) is increasingly used as a treatment for end-stage ankle arthropathy. However, TAA may be more sensitive to complications, failure and subsequent re-operations compared to ankle arthrodesis. The aim of this systematic review and meta-analysis is to generate an overview of complications of TAA surgery.

METHODS

PubMed, EMBASE and the Cochrane library were searched between 2000 and 2020 to identify all papers reporting on complications in TAA surgery. Meta-analysis was conducted based on type of complication in TAA surgery. Pooled estimates of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates was rated and described according to the recommendations of the GRADE working group.

RESULTS

One hundred twenty-seven studies were included in this systematic review. All combined, they reported on 16.964 TAAs with an average follow-up of 47.99 ± 29.18 months. Complications with highest reported pooled incidence were intra-operative fracture 0.06 (95 %CI 0.04-0.08) (GRADE Very low) and impingement 0.06 (95 %CI 0.04-0.08) (GRADE low) respectively.

CONCLUSION

Reported complication incidence of TAA surgery is still high and remains a significant clinical problem that can be severely hampering long-term clinical survival of the prosthesis. The results of this systematic review and meta-analysis can help guide surgeons in informing their patient about complication risks. Implementation of more stringent patient selection criteria might contribute to diminishing TAA complication rates.

Systemic medical complications following total ankle arthroplasty: A review of the evidence

BACKGROUND

Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent.

METHODS

We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA.

RESULTS

The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration.

CONCLUSIONS

When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit

INTRODUCTION

To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres.

METHODS

Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET.

RESULTS

Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance.

CONCLUSIONS

The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

Release of individual surgeon data to the public: patients' and surgeons' views

BACKGROUND

Limited surgeon-specific outcomes data are currently released to the public. Existing schemes generally result from the recommendations of public enquiries, addressing breaches to patient safety and malpractice. We found limited evidence in the literature about patients' or orthopaedic surgeons' wishes regarding the release of such data to the public.

METHODS

We surveyed 80 joint replacement patients and 41 orthopaedic surgeons regarding their wishes concerning collection and release of individual surgeon data to the public.

RESULTS

Of 80 patients, 30% (24/80) were aware of data on the NHS-My Choices website, 16% (13/80) had reviewed data prior to operation and 95% (76/80) wanted data concerning surgeons' experience, length of stay and complications including revisions. Patients expected more current monitoring of data than occurs. Of 41 surgeons, 20% (8/41) thought national joint registry (NJR) derived data accurately reflected their NHS work. Surgeons did not think this data improved patient outcomes (34%, 14/41), and that it reduced innovation (61%, 25/41) and training (75%, 31/41) and increased risk of adverse behaviour (61%, 25/41). Surgeons wanted a minimal data set accurately presented and risk adjusted.

CONCLUSION

In the future, it is likely that more individual surgeon data will be released to the public. There needs to be an agreed, accurate minimum dataset collected, reviewed in local clinical governance meetings and published with explanatory notes regarding the interfering variables and what conclusions can be drawn regarding the ability of the surgeon. This process needs to be overseen by an independent body trusted by the public.

Updates in postoperative imaging modalities following musculoskeletal surgery

Postoperative imaging following orthopaedic surgeries is essential in assessing complications post-surgery and also helps plan further treatment. Combining a high degree of clinical insight with appropriate imaging can guide the treating clinician to the correct diagnosis. Imaging is quite challenging because of surgery-related soft tissue changes, especially in the early postoperative period and the presence of metal implants resulting in image scatter and metal artifacts. Newer modalities and advances in imaging have helped overcome shortcomings and assess better, especially in procedures that involve implants. Collaborative decision-making involving radiologists and clinicians has shown to be beneficial and is the way forward. This narrative review discusses the utility of imaging in evaluating postoperative complications following musculoskeletal surgeries with specific relation to trauma, arthroplasty, and tumour by discussing commonly encountered clinical scenarios.

Reporting Complications in Spinal Surgery-a Systematic Literature Review

BACKGROUND

Many efforts are expended to improve health care quality in the surgical treatment of spinal conditions. However, the prevalence of reporting complications in spinal surgeries is highly heterogeneous, which is partially due to the lack of a universal and comprehensive system.

METHODS

A systematic review of the literature was performed in 5 international and indexed spine journals from January to December 2020. All clinical studies that had surgical procedures in any spinal region were classified according to level of evidence, study design, category of spinal condition, and primary outcome. The prevalence and quality of complication reporting were evaluated through a checklist.

RESULTS

Of 455 articles screened, complications were reported in 64.2% (292 articles). A significant higher prevalence of reports was observed in randomized compared with nonrandomized studies (P < 0.05). In 89 articles, at least 1 classification was used to report complications, with 12 different classification systems employed in the total sample. Timing to record complications was as follows: 47 (16.1%) articles reported complications at 30 days, 31 (10.6%) reported complications at 90 days, and 88 (30.1%) reported complications during all follow-ups. In 126 (43.1%) articles, complications were not mentioned.

CONCLUSIONS

Almost one-third of spine surgical studies did not report complications in their results despite reporting clinical outcomes. The evidence quality of the study was directly related with the reporting of complications. A high heterogeneity regarding complication reporting was seen in the literature.

An Estimation of Lifetime Fatal Carcinogenesis Risk Attributable to Radiation Exposure in the First Year Following Polytrauma: A Major Trauma Center's Experience Over 10 Years

BACKGROUND

The utilization of medical imaging continues to rise, including routine use in major trauma centers. The aims of this study were to estimate the amount of radiation exposure from radiographic imaging and the associated fatal carcinogenesis risk among patients treated for polytrauma at 1 institution.

METHODS

Included were patients who were admitted to our institution with an Injury Severity Score (ISS) of ≥16 during the period of January 2007 to December 2016. Records of patients were reviewed to assess exposures to radiation (excluding fluoroscopy) in the 12 months following injury. The risk of developing a fatal cancer of any type was modeled using patient age and sex, on the basis of the International Commission on Radiological Protection (ICRP) recommendations. Estimates of cancer risk were based on the exposure received and then imported into previously developed models.

RESULTS

Overall, 2,394 patients, with a mean ISS of 28.66 (range, 17 to 66), were included in our analysis. The mean total radiation dose received was 30.45 mSv and the median dose was 18.46 mSv. One hundred and fifteen patients (4.8% of the cohort) received ≥100 mSv of radiation. The total patient group had a 3.56% mean risk of fatal carcinogenesis of any type that related solely to medical exposure of radiation as a result of their injuries. In their lifetime, 85 patients would be expected to develop cancer as a result of medical imaging that they had undergone in the year following their accident. The ISS and the body region of injury contributing to the ISS were predictive of the level of radiation exposure.

CONCLUSIONS

Those involved in trauma care can use the ISS and body region to predict radiation exposure and the risk of fatal carcinogenesis of any type. We found that, for injuries to the limb and pelvis, the greater the severity of injury, the greater the radiation exposure and fatal carcinogenesis risk. However, this study does not provide an actuarial analysis. It is unknown how many patients in the study went on to develop cancer.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.