Surgery (St Vincent's) - Research Publications
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ItemImpact of surgical experience on outcomes in total joint arthroplasties(WILEY-BLACKWELL, 2016-12)BACKGROUND: Outcomes of primary total hip and knee arthroplasties performed by consultant surgeons were compared with those performed by orthopaedic trainees. Furthermore, outcomes of these procedures performed by senior trainees were compared with those performed by junior trainees. METHODS: Data from the St Vincent's Melbourne Arthroplasty Outcomes Registry and the surgical log kept by trainees were reviewed to investigate if an association exists between surgical experience and clinical outcomes following primary total hip and knee arthroplasties. Multivariate logistic regression analyses were conducted to produce odds ratios with 95% confidence intervals to assess these relationships. RESULTS: Arthroplasties performed by trainees were not significantly different from those performed by consultant surgeons in regards to medical, surgical and wound complications. Trainee-performed primary total hip arthroplasties were associated with a 30% increase in the risk of requiring a transfusion compared with consultant cases. Primary total knee arthroplasties performed by junior trainees were associated with a 50% increase in the risk of developing a wound complication compared with those performed by senior trainees. CONCLUSIONS: Overall, senior orthopaedic trainees working independently and junior orthopaedic trainees under supervision as the primary surgeon have the ability to achieve a level of clinical outcomes similar to a consultant surgeon. Junior trainees with supervision have the ability to achieve a level of clinical outcomes similar to senior trainees. These findings can be used to further improve orthopaedic training to reduce adverse events during supervised surgery.
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ItemMetastatic bone disease of the pelvis and extremities: rationalizing orthopaedic treatment(WILEY, 2017-11)BACKGROUND: Choosing the appropriate treatment for patients presenting with impending or pathological fractures is difficult and understanding the prognosis based on certain characteristics can help inform the decision to treat and construct to use in a palliative setting. We retrospectively analysed patients presenting with metastatic bone disease in the extremities and pelvis. METHODS: Patients presenting with metastatic bone disease to the extremities or pelvis who underwent orthopaedic treatment from 1996 to 2012 were identified. Survival rates were calculated using life table analysis. Univariate and multivariate analysis was achieved with Cox proportional hazards regression. RESULTS: There were a total of 462 patients. An overall 1-, 2- and 5-year survival rate of 45%, 29% and 13% was identified, respectively. In the multivariate analysis, preoperative haemoglobin was found to be an independent predictor of better survival while lung histotype, age, pathological fracture and previous combined therapy were negative predictors of survival. Patients undergoing prosthetic replacement had a significantly longer period of hospitalization in comparison to those undergoing internal fixation. CONCLUSION: This study has contributed to our understanding of the survival rate and survival prognostication for patients presenting for orthopaedic treatment of metastatic bone disease.
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ItemPredicting the prognosis of undifferentiated pleomorphic soft tissue sarcoma: a 20-year experience of 266 cases(WILEY, 2019-09)BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) is a rare malignant tumour of mesenchymal origin, which was conceived following re-classification of malignant fibrous histiocytoma (MFH). The objective of this study is to determine prognostic factors for the outcome of UPS, following multi-modal treatment. METHODS: Data of UPS tumours from 1996 to 2016 were collected, totalling 266 unique UPS patients. Median follow-up was 7.8 years. All tumours were retrospectively analysed for prognostic factors of the disease, including local recurrence (LR) and metastatic disease (MD) at diagnosis, tumour size, grade, location and depth, patient age, adjuvant therapy and surgical margin. Overall survival (OS), post-treatment LR and metastatic-free survival were assessed as outcomes. RESULTS: The 5- and 10-year OS rates for all ages were 60% and 48%, respectively, with a median survival time of 10.1 years. Multivariate analysis revealed that the adverse prognostic factors associated with decreased OS were older age (P < 0.001; hazard ratio 1.03) and MD at diagnosis (P = 0.001; 2.89), with upper extremity tumours being favourable (P = 0.043; 2.30). Poor prognosis for post-operative LR was associated with older age (P = 0.046; 1.03) and positive surgical margins (P = 0.028; 2.68). Increased post-treatment MD was seen in patients with large tumours (5-9 cm (P < 0.001; 4.42), ≥10 cm (P < 0.001; 6.80)) and MD at diagnosis (P < 0.001; 3.99), adjuvant therapy was favourable, shown to reduce MD (P < 0.001; 0.34). CONCLUSIONS: UPS is a high-grade soft tissue sarcoma, for which surgery striving for negative margins, with radiotherapy, is the treatment of choice. Older age, lower extremity location, MD at presentation, large size and positive surgical margins, were unfavourable.
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ItemNo Preview AvailableThree-dimensional knee kinematic analysis during treadmill gait SLOW IMPOSED SPEED VERSUS NORMAL SELF-SELECTED SPEED(BRITISH EDITORIAL SOC BONE JOINT SURGERY, 2017-08)OBJECTIVES: Whilst gait speed is variable between healthy and injured adults, the extent to which speed alone alters the 3D in vivo knee kinematics has not been fully described. The purpose of this prospective study was to understand better the spatiotemporal and 3D knee kinematic changes induced by slow compared with normal self-selected walking speeds within young healthy adults. METHODS: A total of 26 men and 25 women (18 to 35 years old) participated in this study. Participants walked on a treadmill with the KneeKG system at a slow imposed speed (2 km/hr) for three trials, then at a self-selected comfortable walking speed for another three trials. Paired t-tests, Wilcoxon signed-rank tests, Mann-Whitney U tests and Spearman's rank correlation coefficients were conducted using Stata/IC 14 to compare kinematics of slow versus self-selected walking speed. RESULTS: Both cadence and step length were reduced during slow gait compared with normal gait. Slow walking reduced flexion during standing (10.6° compared with 13.7°; p < 0.0001), and flexion range of movement (ROM) (53.1° compared with 57.3°; p < 0.0001). Slow walking also induced less adduction ROM (8.3° compared with 10.0°; p < 0.0001), rotation ROM (11.4° compared with 13.6°; p < 0.0001), and anteroposterior translation ROM (8.5 mm compared with 10.1 mm; p < 0.0001). CONCLUSION: The reduced spatiotemporal measures, reduced flexion during stance, and knee ROM in all planes induced by slow walking demonstrate a stiff knee gait, similar to that previously demonstrated in osteoarthritis. Further research is required to determine if these characteristics induced in healthy knees by slow walking provide a valid model of osteoarthritic gait.Cite this article: N. Mannering, T. Young, T. Spelman, P. F. Choong. Three-dimensional knee kinematic analysis during treadmill gait: Slow imposed speed versus normal self-selected speed. Bone Joint Res 2017;6:514-521. DOI: 10.1302/2046-3758.68.BJR-2016-0296.R1.
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ItemMulticentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial(BMJ PUBLISHING GROUP, 2019-11)INTRODUCTION: Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established. METHODS AND ANALYSIS: This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis. ETHICS AND DISSEMINATION: The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums. TRIAL REGISTRATION NUMBER: ACTRN12618000642280.
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ItemPatient-related risk factors for unplanned 30-day readmission following total knee arthroplasty: a protocol for a systematic review and meta-analysis(BMC, 2019-08-22)BACKGROUND: Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty is an effective treatment for advanced stages of disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. The objective is to perform a systematic review of patient-related factors associated with unplanned 30-day readmission following total knee arthroplasty. This information will inform future strategies to improve health outcomes after knee arthroplasty surgery. METHODS: MEDLINE and EMBASE will be systematically searched using a comprehensive search strategy. Studies of higher quality than case series will be included, in order to optimise the quality of the findings of this review. We will include studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision total knee arthroplasty for any indication. Case series will be excluded, as will studies reporting exclusively on intraoperative, clinician, hospital, and health system risk factors. The reference lists of selected papers will then be screened for any additional literature. Two reviewers will independently apply stringent eligibility criteria to titles, abstracts, and full texts of studies identified in the literature search. They will then extract data from the final list of selected papers according to an agreed-upon taxonomy and vocabulary of the data to be extracted. Assessment of risk of bias and quality of evidence will then take place. Finally, the effect size of each identified risk factor will be determined; meta-analysis will be performed where adequate data is available. DISCUSSION: The findings of this review and subsequent meta-analysis will aid clinicians as they seek to understand the risk factors for 30-day readmission following total knee arthroplasty. Clinicians and patients will be able to use this information to align expectations of the postoperative course, which will enhance the recovery process, and aid in the development of strategies to mitigate identified risks. Another purpose of this review is to assist policy-makers in developing quality indicators for care and provide insights into the drivers of health costs. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019118154.
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ItemThe effect of mindfulness training prior to total joint arthroplasty on postoperative pain and physical function: A randomised controlled trial(CHURCHILL LIVINGSTONE, 2019-10)OBJECTIVE: To evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA). DESIGN: Two-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017. SETTING: Single centre study conducted at a University-affiliated, tertiary hospital. INTERVENTION: People with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU). OUTCOME MEASURES: Self-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire). RESULTS: 127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed. CONCLUSION: MBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.