Resuming motor vehicle driving following orthopaedic surgery or limb trauma.

Following elective orthopaedic surgery or the treatment of a fracture, patients are temporarily unable to drive. This loss of independence may have serious social and economic consequences for the patient. It is therefore essential to know when it is safe to permit such patients to return to driving. This article, based upon a review of the current literature, proposes recommendations of the time period after which patients may safely return to driving. Practical decisions are made based upon the type of surgical intervention or fracture. Swiss legislation is equally approached so as to better define the decision.

Predictors of physiotherapy and occupational therapy use two years after a vocational rehabilitation for orthopaedic trauma

Introduction.- Health care utilization is an important field of our economy. Nevertheless a minority of cases induce the majority of costs. For instance, in the setting of accident insurance, the most expensive 5% of all injured cases involve 80% of the health care costs. Although physiotherapy and occupational therapy consist of only a small proportion of these costs, it is nevertheless important to evaluate the factors that predict its use in order to improve services (i.e. allocation of resources to those who need them and benefit most).Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 consecutively included patients with orthopaedic problems attending the clinique Romande de réadaptation (CRR) at Sion for inpatient rehabilitation after a work, traffic or leisure related injury. Two years after discharge, a questionnaire regarding the use of different health cares was send to the patients (1502 patients returned their questionnaires). The aim of this study was to calculate, with a logistic multivariate model, in-patient hospitalized for orthopaedic problems, the variables that mostly predict physiotherapy use 2 years after discharge.Results.- The full multivariate model contains 46 predictors. The use of physiotherapy and occupational therapy was significantly predicted in this multivariate model by the following predictors: Patients with a spinal problem (OR 1.51 versus lower-extremity problem, 95% CI 1.01 to 2.27), a disability pension (OR 1.69, 95% CI 1.09 to 2.60), patients with sports activities (OR 1.56, 95% CI 1.26 to 1.94), patients with longer stay at the rehabilitation clinic (OR 1.22 per week, 95% CI 1.05 to 1.41), women (OR 1.64, 95% CI 1.09 to 2.48) and those consulting a psychiatrist (OR 1.66, 95% CI 1.06 to 2.60).Discussion.- In this prospective study with a 2-year follow-up, different factors predicted the use of physiotherapy and occupational therapy after an injury. Further studies are needed to clarify the impact of these factors for the health care utilization and the strategies, which would allow to improve allocation of available resources.

INTERMED predicts non-return to work in an occupational rehabilitation setting for individuals with orthopaedic trauma-part 2

Introduction.- The model presented in part I (19 predictors) had good predictive values for non-return to work 2 years after vocational rehabilitation for orthopaedic trauma. However, the number of predictors is high for the detection of patients at risk in a clinic. For example, the INTERMED for itself consists of 20 questions and needs 20 minutes to be filled in. For this reason, the aim of this study was to compare the predictive value of different models for the prediction of non-return to work.Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 included inpatients with orthopaedic trauma attending a rehabilitation hospital after a work, traffic, sport or leisure related injury. Two years after discharge, 1502 patients returned a questionnaire regarding return to work. We compared the area under the receiver-operator-characteristics curve (ROC) between different models: INTERMED total score, the 4 partial INTERMED scores, the items of the most predictive partial score; with or without confounders.Results.- The ROC for the total score of the INTERMED plus the five confounders of the of the part one (qualified work, speaking French, lesion of upper extremity, education and age) was 0.72. The sole partial INTERMED score to predict return to work was the social sub score. The ROC for the five items of the latter sub score of the INTERMED was 0.69. The ROC for the five items of the social subscale of the INTERMED combined with five predictors was 0.73. This was significantly better than the use of only the five items from INTERMED alone (delta 0.034; 95% CI 0.017 to .050). The model presented in part I (INTERMED total score plus 18 predictors) was not significantly better than the five items INTERMED social score plus five confounders.Discussion.- The use of a model with ten variables (INTERMED social five items plus five confounders) has good predictive value to detect patients not returning to work after vocational rehabilitation after orthopaedic trauma. The parsimony of this model facilitates its use in a clinic for the detection of patients at risk.

Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL).

Extended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p < 0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%), gastrointestinal (19%), and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylaxis was longer in patients with orthopaedic surgery (32 days, interquartile range 14-40 days) than in patients with cancer surgery (23 days, interquartile range 11-30 days; p<0.001). Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

Predicting Non Return to Work after Orthopaedic Trauma: The Wallis Occupational Rehabilitation RisK (WORRK) Model.

BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.

Subjective perceptions as prognostic factors of time to fitness for work during a 4-year period after inpatient rehabilitation for orthopaedic trauma.

INTRODUCTION: Time to fitness for work (TFW) was measured as the number of days that were paid as compensation for work disability during the 4 years after discharge from the rehabilitation clinic in a population of patients hospitalised for rehabilitation after orthopaedic trauma. The aim of this study was to test whether some psychological variables can be used as potential early prognostic factors of TFW. MATERIAL AND METHODS: A Cox proportional hazards model was used to estimate the associations between predictive variables and TFW. Predictors were global health, pain at hospitalisation and pain decrease during the stay (all continuous and standardised by subtracting the mean and dividing by two standard deviations), perceived severity of the trauma and expectation of a positive evolution (both binary variables). RESULTS: Full data were available for 807 inpatients (660 men, 147 women). TFW was positively associated with better perceived health (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.13-1.19), pain decrease (HR 1.46, 95% CI 1.30-1.64) and expectation of a positive evolution (HR 1.50, 95% CI 1.32-1.70) and negatively associated with pain at hospitalisation (HR 0.67, 95% CI 0.59-0.76) and high perceived severity (HR 0.72, 95% CI 0.61-0.85). DISCUSSION: The present results provide some evidence that work disability during a four-year period after rehabilitation may be predicted by prerehabilitation perceptions of general health, pain, injury severity, as well as positive expectation of evolution.

Indirect comparison meta-analysis of two enoxaparin regimens in patients undergoing major orthopaedic surgery. Impact on the interpretation of thromboprophylactic effects of new anticoagulant drugs.

Two enoxaparin dosage regimens are used as comparators to evaluate new anticoagulants for thromboprophylaxis in patients undergoing major orthopaedic surgery, but so far no satisfactory direct comparison between them has been published. Our objective was to compare the efficacy and safety of enoxaparin 3,000 anti-Xa IU twice daily and enoxaparin 4,000 anti-Xa IU once daily in this clinical setting by indirect comparison meta-analysis, using Bucher's method. We selected randomised controlled trials comparing another anticoagulant, placebo (or no treatment) with either enoxaparin regimen for venous thromboembolism prophylaxis after hip or knee replacement or hip fracture surgery, provided that the second regimen was assessed elsewhere versus the same comparator. Two authors independently evaluated study eligibility, extracted the data, and assessed the risk of bias. The primary efficacy outcome was the incidence of venous thomboembolism. The main safety outcome was the incidence of major bleeding. Overall, 44 randomised comparisons in 56,423 patients were selected, 35 being double-blind (54,117 patients). Compared with enoxaparin 4,000 anti-Xa IU once daily, enoxaparin 3,000 anti-Xa IU twice daily was associated with a reduced risk of venous thromboembolism (relative risk [RR]: 0.53, 95% confidence interval [CI]: 0.40 to 0.69), but an increased risk of major bleeding (RR: 2.01, 95% CI: 1.23 to 3.29). In conclusion, when interpreting the benefit-risk ratio of new anticoagulant drugs versus enoxaparin for thromboprophylaxis after major orthopaedic surgery, the apparently greater efficacy but higher bleeding risk of the twice-daily 3,000 anti-Xa IU enoxaparin regimen compared to the once-daily 4,000 anti-Xa IU regimen should be taken into account.

Cognitively Empowering Internet-Based Patient Education for Ambulatory Orthopaedic Surgery Patients

Tiedollista voimavaraistumista tukeva internet-perustainen ohjaus päiväkirurgisille ortopedisille potilaille Tutkimuksen tarkoituksena oli kehittää tiedollista voimavaraistumista tukeva Internetperustainen potilasohjausohjelma sekä arvioida sitä. Tutkimusprosessi jaettiin kahteen vaiheeseen. Ensimmäisessä vaiheessa luotiin sisältö tiedollista voimavaraistumista tukevalle Internet-perustaiselle ohjaukselle päiväkirurgisia ortopedisia potilaita varten. Toisessa vaiheessa arvioitiin Internet-perustaisen ohjauksen (koeryhmä) hyväksyttävyyttä käyttäjien arvioimana ja ohjauksen tuloksia sekä verrattiin Internet-perustaisen ohjauksen (koeryhmä) tuloksia tiedollisesti voimavaraistumista tukevan sairaanhoitajan välittämään ohjauksen (kontrolliryhmä) tuloksiin. Tutkimuksen tavoitteena oli luoda uusi potilasohjausmuoto joka tarjoaa yksilöllisen, osallistavan ja aikaan ja paikkaan sitomattoman ohjauksen päiväkirurgiseen ortopediseen leikkaukseen tulevalle potilaalle. Tutkimuksen ensimmäisessä vaiheessa käytettiin kuvailevaa ja vertailevaa tutkimusmenetelmää (ennen ja jälkeen testaus). Tutkimukseen osallistui 120 päiväkirurgista ortopedista potilasta joiden tiedon odotuksia ja heille välitettyä tietoa tarkasteltiin. Tutkimuksen ensimmäisen vaiheen tuloksien ja aikaisemman voimavaraistumista käsittävän tiedon perusteella luotiin sisältö tiedollista voimavaraistumista tukevalle Internet-perustaiselle ohjaukselle. Sisältö rakentui voimavaraistavan tiedon kuudesta eri osa-alueesta. Tutkimuksen toisessa vaiheessa käytettiin randomoitua kokeellista tutkimusasetelmaa. Päiväkirurgiseen ortopediseen leikkaukseen tulevat potilaat randomoitiin koeryhmään (n=72) Internetperustaiseen ohjaukseen ja kontrolliryhmään (n=75) sairaanhoitajan välittämään ohjaukseen. Aineisto kerättiin strukturoitujen mittareiden avulla ja tulokset analysoitiin tilastollisesti. Tutkimuksen tulokset osoittavat, että kehitettyä tiedollisesti voimavaraistumista tukevaa Internet-perustaista potilasohjausmenetelmää voidaan suositella käytettäväksi ortopedisten päiväkirurgisten potilaiden ohjauksessa ja potilailla on hyvät mahdollisuudet voimavaraistua tiedollisesti sen avulla. Monipuolista tietoa sisältävä Internet-perustainen ohjaus osoittautui käyttäjien näkökulmasta hyväksyttäväksi. Vaikka Internet ohjauksen hyväksyttävyys koettiin osittain heikommaksi kuin sairaanhoitajan välittämän ohjauksen, potilaat käyttivät nettisivustoa ongelmitta ja arvioivat sen helppokäyttöiseksi. Ohjausmuodolla ei ollut vaikutusta hoidosta aiheutuneisiin kustannuksiin. Sen sijaan kustannuksista organisaatiolle voitiin puolittaa sairaanhoitajan ohjaukseen käyttämä aika Internet-perustaisen ohjauksen avulla. Internet-perustaiseen ohjaukseen osallistuneiden potilaiden tiedon taso ja kokemus tiedon riittävyydestä lisääntyivät ohjauksen jälkeen enemmän kuin sairaanhoitajan välittämään potilasohjaukseen osallistuneiden potilaiden tiedot. Ohjausmuodolla ei ollut vaikutusta potilaiden kokemien tunteiden ja oireiden voimakkuuteen. Yhteenvetona voidaan todeta, että tiedollisesti voimavaraistava Internet-perustaista ohjausta voidaan suositella vaihtoehtoiseksi menetelmäksi sairaanhoitajan välittämälle ohjaukselle päiväkirurgiseen ortopediseen leikkaukseen tuleville potilaille.

Pharmacokinetics of Oxycodone and Paracetamol in the Elderly. Clinical Pharmacokinetic Study on Orthopaedic Surgical Patients and Healthy Volunteers

The proportion of elderly people over 65 years of age in Finland is expected to grow to over 25% by the 2025. It has been estimated that elderly people today consume nearly 40% of all drugs. Age brings about number of physiological changes that may affect the disposition, metabolism and excretion of drugs. The function of heart, lungs, liver and kidneys decreases even in healthy people, as they get older. The proportion of total body water decreases and the relative fat percentage increases. Also several other factors such as concurrent diseases, concomitant medication and nutritional factors have an effect on drug therapy in elderly. Age increases the risk of adverse drug reactions, which most often are dose-dependent. Despite all this there are not enough studies involving the elderly people and the elderly are most often excluded from clinical trials. Oxycodone is a strong opioid analgesic, which is used to treat moderate or severe pain. Paracetamol is a widely used nonopioid analgesic, which has become popular in the treatment of pain in many patient groups. In this series of studies the pharmacokinetics of oral and intravenous oxicodone as well as intravenous paracetamol in the elderly and young adult patients were investigated. Also a study investigating the interaction of oral antibiotic clarityhromycin, a known cytochrome P450 (CYP) 3A4 inhibitor, with oxycodone pharmacokinetics and pharmacodynamics in elderly and young healthy volunteers was carried out. The pharmacokinetics of oxycodone showed a clear age depency. Patients over 70 years had 50-80% higher mean exposure to oral oxycodone and a twofold greater plasma concentration than young adults 12 h after ingestion of the drug. Elderly patients had 40-80% greater exposure to intravenous oxycodone and patients over 80 years had over twofold greater plasma concentrations 8 h post dose than the young adults. The elderly patients had also greater exposure to intra venous paracetamol compared to young adults. Clarithromycin increased the exposure to oral oxycodone in both young and elderly volunteers. The elderly had marked interindividual variation in the pharmacokinetics and pharmacodynamics when clarithromycin was given concomitantly with oxycodone. Because the pharmacokinetics of oxycodone and intravenous paracetamol depend on the age of the subject, it is important to titrate the analgesic dose individually in the elderly.

Anaesthesia and Pain Management for Use in Orthopaedic Day Surgery

Day surgery has gained a large popularity during the last decades. In Finland, 57% of the elective procedures, and 50% at Turku University Hospital, were already conducted on day basis during 2012. The steady growth of day surgery is mostly due to an increased safety in perioperative care and cost-effectiveness. The development of surgical techniques and anaesthetic methods has advanced the modern day surgery and extended the repertory of the procedures for use in day surgery operations. Day surgery also offers certain benefits like reduced risk for hospital-related infections, stress and confusion. Patient satisfaction, regarding several issues, is high. Most concerns and complaints are related to postoperative pain, nausea and vomiting pain and nausea. Pain can hamper recovery and pain management is a crucial factor for hospital discharge. Appropriate pain treatment is effective, safe, easy and economical. A procedure-specific approach and an individually planned, multimodal analgesia should be the basis of modern pain management. The main aim of this thesis was to evaluate the effectiveness and safety of anaesthetic technique and methods in pain treatment of orthopaedic day case surgery, and following conclusions were made. Unilateral spinal block was achieved using hyperbaric bupivacaine with a small dose of clonidine but clonidine prolonged the block. Continuous subacromial bupivacaine was found to be safe but conferring only moderate efficacy in pain care after shoulder arthroscopy. Transdermal fentanyl, 12 g/h, as part of multimodal analgesia, offered a safe and easy option to pain management in this patient group. However, after forefoot surgery, it did not reduce pain any further. In general, pain scores in all patient groups were low and the need for rescue opioid moderate.

Nutritional status and clinical outcome in elderly female surgical orthopaedic patients

The possible relationship between nutritional status and clinical outcome following orthopaedic hip surgery was investigated. The nutritional status of 60 elderly female patients admitted for elective total hip replacement (THR) and emergency fractured neck of femur surgery (FNF) was measured over time. Specific measures of clinical outcome, including well-being and functional status, were monitored during hospital stay and at 4, 8 and 26 weeks following discharge. Patients were allocated to a high nutritional risk group where any three of the following were less than the 5th percentile value: serum albumin, haemoglobin, triceps skinfold thickness, mid-upper arm muscle circumference and body weight. Using this definition, malnutrition was present in 4% of THR patients and 41% of FNF patients. It was found that the high risk patients had significantly longer convalescence periods, (median stay27.5 days compared with 0 days, P < 0.0009), and a greater proportion were dependent upon walking frames at 6 months (46% compared with 11%, P < 0.01). Fifty percent of the high risk patients had been living independently prior to admission, in contrast only 29% had returned to their homes at 6 months after discharge. The results indicate an apparent link between clinical outcome and nutritional status based upon the allocation procedure employed, which has the potential for ensuring cost-effective nutritional intervention.

A controlled trial of sip-feed supplements in elderly orthopaedic patients

The potential nutritional and clinical benefits of sip-feed supplements were investigated by means of a controlled trial in elderly female patients admitted for orthopaedic surgery. A nutritional risk assessment procedure (Nutritional Risk Questionnaire, NRQ) was used to identify patients who might benefit from supplementation. Patients identified as high risk who did not receive supplements showed significant losses in triceps skinfold thickness (TSF) and mid-upper arm muscle circumference (MUAMC) measurements during hospitalization. Such changes were not observed in high-risk supplemented patients, but significant losses of MUAMC were also recorded in a group of patients who failed to comply with the supplement. No differences in biochemical parameters, muscle function, or clinical outcome were observed between supplemented and unsupplemented and non-compliant patients. The problems of poor compliance to sip-feed supplements and failure to observe clinical benefit in supplemented patients are discussed.