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Abstract Background Prediction models for poor patient-reported surgical outcomes after total hip replacement (THR) and total knee replacement (TKR) may provide a method for improving appropriate surgical care for hip and knee osteoarthritis. There are concerns about methodological issues and the risk of bias of studies producing prediction models. A critical evaluation of the methodological quality of prediction modelling studies in THR and TKR is needed to ensure their clinical usefulness. This systematic review aims to (1) evaluate and report the quality of risk stratification and prediction modelling studies that predict patient-reported outcomes after THR and TKR; (2) identify areas of methodological deficit and provide recommendations for future research; and (3) synthesise the evidence on prediction models associated with post-operative patient-reported outcomes after THR and TKR surgeries. Methods MEDLINE, EMBASE, and CINAHL electronic databases will be searched to identify relevant studies. Title and abstract and full-text screening will be performed by two independent reviewers. We will include (1) prediction model development studies without external validation; (2) prediction model development studies with external validation of independent data; (3) external model validation studies; and (4) studies updating a previously developed prediction model. Data extraction spreadsheets will be developed based on the CHARMS checklist and TRIPOD statement and piloted on two relevant studies. Study quality and risk of bias will be assessed using the PROBAST tool. Prediction models will be summarised qualitatively. Meta-analyses on the predictive performance of included models will be conducted if appropriate. A narrative review will be used to synthesis the evidence if there are insufficient data to perform meta-analyses. Discussion This systematic review will evaluate the methodological quality and usefulness of prediction models for poor outcomes after THR or TKR. This information is essential to provide evidence-based healthcare for end-stage hip and knee osteoarthritis. Findings of this review will contribute to the identification of key areas for improvement in conducting prognostic research in this field and facilitate the progress in evidence-based tailored treatments for hip and knee osteoarthritis. Systematic review registration PROSPERO registration number CRD42021271828.

Abstract Background This a priori statistical analysis plan describes the analysis for CRISTAL. Methods CRISTAL (cluster-randomised, crossover, non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty, a registry nested study) aims to determine whether aspirin is non-inferior to low molecular weight heparin (LMWH) in preventing symptomatic venous thromboembolism (VTE) following hip arthroplasty (HA) or knee arthroplasty (KA). The study is nested within the Australian Orthopaedic Association National Joint Replacement Registry. The trial was commenced in April 2019 and after an unplanned interim analysis, recruitment was stopped (December 2020), as the stopping rule was met for the primary outcome. The clusters comprised hospitals performing > 250 HA and/or KA procedures per annum, whereby all adults (> 18 years) undergoing HA or KA were recruited. Each hospital was randomised to commence with aspirin, orally, 85–150 mg daily or LMWH (enoxaparin), 40 mg, subcutaneously, daily within 24 h postoperatively, for 35 days after HA and 14 days after KA. Crossover was planned once the registration target was met for the first arm. The primary end point is symptomatic VTE within 90 days. Secondary outcomes include readmission, reoperation, major bleeding and death within 90 days, and reoperation and patient-reported pain, function and health status at 6 months. The main analyses will focus on the primary and secondary outcomes for patients undergoing elective primary total HA and KA for osteoarthritis. The analysis will use an intention-to-treat approach with cluster summary methods to compare treatment arms. As the trial stopped early, analyses will account for incomplete cluster crossover and unequal cluster sizes. Conclusions This paper provides a detailed statistical analysis plan for CRISTAL. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12618001879257 . Registered on 19/11/2018.

Abstract Background Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. Method A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. Results Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p

Abstract Background Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery. Methods Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol ‘today’ health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and β coefficients (standard error) were calculated. Results Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [β 0.40 (0.07), p

Abstract Background Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers’ compensation schemes. Methods Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models. Results The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50). Conclusions Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.

Abstract Background The clinimetric properties of knee goniometry are essential to appreciate in light of its extensive use in the orthopaedic and rehabilitative communities. Intra-observer reliability is thought to be satisfactory, but the validity and inter-rater reliability of knee goniometry often demonstrate unacceptable levels of variation. This study tests the validity and reliability of measuring knee range of motion using goniometry and photographic records. Methods Design: Methodology study assessing the validity and reliability of one method ('Marker Method') which uses a skin marker over the greater trochanter and another method ('Line of Femur Method') which requires estimation of the line of femur. Setting: Radiology and orthopaedic departments of two teaching hospitals. Participants: 31 volunteers (13 arthritic and 18 healthy subjects). Knee range of motion was measured radiographically and photographically using a goniometer. Three assessors were assessed for reliability and validity. Main outcomes: Agreement between methods and within raters was assessed using concordance correlation coefficient (CCCs). Agreement between raters was assessed using intra-class correlation coefficients (ICCs). 95% limits of agreement for the mean difference for all paired comparisons were computed. Results Validity (referenced to radiographs): Each method for all 3 raters yielded very high CCCs for flexion (0.975 to 0.988), and moderate to substantial CCCs for extension angles (0.478 to 0.678). The mean differences and 95% limits of agreement were narrower for flexion than they were for extension. Intra-rater reliability: For flexion and extension, very high CCCs were attained for all 3 raters for both methods with slightly greater CCCs seen for flexion (CCCs varied from 0.981 to 0.998). Inter-rater reliability: For both methods, very high ICCs (min to max: 0.891 to 0.995) were obtained for flexion and extension. Slightly higher coefficients were obtained for flexion compared to extension, and with the Marker compared to the Line of Femur Method. For intra- and inter-rater reliability, the mean differences (within 2 degrees) and 95% limits of agreement (within 5 degrees) were generally clinically acceptable for both methods. Conclusion Photography potentially offers a superior method of measurement over standard goniometry as visualising the centre of the knee is simplified in a two-dimensional plane and the permanent record provides greater assessor transparency as well as opportunity to confer. The Marker and Line of Femur Methods have moderate to substantial validity, but the inter- and intra-rater repeatability for trained observers are excellent with both methods yielding small mean differences with narrow limits of agreement. The Line of Femur Method offers the added advantage that it does not rely on inter-clinician consistency in identifying the greater trochanter.

Abstract Background Regions of interest identified through genetic linkage studies regularly exceed 30 centimorgans in size and can contain hundreds of genes. Traditionally this number is reduced by matching functional annotation to knowledge of the disease or phenotype in question. However, here we show that disease genes share patterns of sequence-based features that can provide a good basis for automatic prioritization of candidates by machine learning. Results We examined a variety of sequence-based features and found that for many of them there are significant differences between the sets of genes known to be involved in human hereditary disease and those not known to be involved in disease. We have created an automatic classifier called PROSPECTR based on those features using the alternating decision tree algorithm which ranks genes in the order of likelihood of involvement in disease. On average, PROSPECTR enriches lists for disease genes two-fold 77% of the time, five-fold 37% of the time and twenty-fold 11% of the time. Conclusion PROSPECTR is a simple and effective way to identify genes involved in Mendelian and oligogenic disorders. It performs markedly better than the single existing sequence-based classifier on novel data. PROSPECTR could save investigators looking at large regions of interest time and effort by prioritizing positional candidate genes for mutation detection and case-control association studies.

Abstract Background Regional anesthesia (RA) can improve patient outcomes and reduce perioperative complications including deaths. Despite its benefits, RA is less utilised in low-resource settings. The purpose of this study was to assess practice and challenges related to RA in Amhara Regional Hospitals, Northwest-Ethiopia. Methods A web- based survey was distributed among 360 anesthetists working in Amhara Regional Hospitals, Northwest-Ethiopia from November 15 - January 30, 2023. An English, semi-structure, self-administered questionnaire was disseminated by email and telegram following ethical clearance. The survey included questions about the use of RA, socio-demographic characteristics of anesthetist, types of practiced regional blocks, and barriers to perform RA. All volunteer respondents who filled online questionnaire during study period were included. The data were coded and analyzed using statistical package for social Sciences (SPSS) software-version 20. Both inferential and descriptive statistics were used to describe the results. Results The overall response rate was 63.3% (223 out of 360 completed surveys). A total of 132 respondents (36.7%) did not provide a response, and 5 respondents (1.4%) submitted incomplete) surveys. The most frequently self-reported barriers to performing peripheral nerve blocks were a lack of equipment (regional procedure kit including block needle, ultrasound, nerve stimulator, or epidural set) 185 (82.9%), lack of knowledge 171(76.7%), lack of practical skills 112 (50.2%), and lack of drugs/medication 50 (22.4%). Conclusions The principal findings indicate that all respondents perform spinal anaesthesia, while the practice of peripheral RA varies. Reported barriers to performing RA are related to knowledge and training, as well as a lack of equipment (there aren’t enough regional procedure kits available that include an epidural set, block needle, nerve stimulator, and ultrasound). A more stringent approach with specific requirements, distinguishing between neuraxial and peripheral blocks, enhance training opportunities for peripheral nerve blocks are required in Ethiopia.

Abstract Background Nosocomial infections pose a global health threat, with Ventilator-Associated Pneumonia (VAP) emerging as a prominent hospital-acquired infection, particularly in intensive care units (ICU).VAP is the commonest form of pneumonia in ICUs, contributing significantly to morbidity and mortality rates, which can reach around 30%. Despite the substantial impact of VAP on healthcare, there is a lack of data on adherence to VAP prevention protocols in our hospital. Consequently, this study aims to assess the adherence to ventilator-associated pneumonia care bundles in critical care units at a comprehensive specialized hospital in northwest Ethiopia. Methods A hospital-based prospective observational study was conducted from July 3, 2022, to January 7, 2024. All adult patients who were on mechanical ventilators for more than 48 h during the study period were included. Data were collected using the Institute of Healthcare Improvement VAP prevention standards as checklists via direct observation and chart review. The data were entered and analyzed using SPSS version 20. Results A total of 300 surgical and medical ICU patients were observed. Among the patients, 66.3% were from the medical ICU. In terms of admission reasons, 22.3%, 15.7% and, 12% were attributed to infections excluding respiratory origin, respiratory disorders, and other causes, respectively. The rate of compliance with all components of the bundle was 70%. A 100% adherence rate was observed for the prophylaxis for peptic ulcer and deep vein thrombosis (DVT). The lowest adherence rate was observed in the practice of oral hygiene with 0.5% chlorhexidine solution (0%) followed by humidification with heat and moisture exchangers (23.3%). Endotracheal tube cuff pressure measurement and use of endotracheal tubes with subglottic suction were not applicable. Conclusion The study revealed suboptimal compliance with the VAP care bundle, indicating unsatisfactory overall practice. Specific attention is warranted for subglottic suction, cuff pressure measurement, humidification, oral care with chlorhexidine, and sedation vacation.

Abstract Background Postoperative hyperglycemia is associated with morbidity and mortality in non-diabetic surgical patients. However, there is limited information on the extent and factors associated with postoperative hyperglycemia. This study assessed the magnitude and associated factors of postoperative hyperglycemia among non-diabetic adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Methods A facility-based cross-sectional study was conducted among 412 adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital from April 14 to June 30, 2022 All consecutive postoperative non-diabetic elective surgical patients who were admitted to PACU during the data collection period and who fulfilled inclusion criteria were included in the study until the intended minimum sample size was achieved. And data were collected through interviews using a pretested semi-structured questionnaire. Postoperative hyperglycemia was defined as a blood glucose level of ≥ 140 mg/dl. Multivariable logistic regression was performed to identify the association between postoperative hyperglycemia and independent variables. Variables with a p-value less than 0.05 and a 95% confidence interval (CI) were considered statistically significant. Results A total of 405 patients’ data were evaluated with a response rate of 98.3%. The median (IQR) age was 40 (28-52) years. The prevalence of postoperative hyperglycemia was 34.1% (95% CI: 29.4–39.0). Factors significantly associated with postoperative hyperglycemia included being overweight (AOR = 5.45, 95% CI: 2.46-12.0), American Society of Anesthesiologists (ASA) classification II and III (AOR = 2.37, 95% CI: 1.17–4.79), postoperative low body temperature (AOR = 0.18, 95% CI: 0.069–0.48), blood loss ≥ 500 ml (AOR = 2.33, 95% CI: 1.27–4.27), long duration of surgery, mild pain (AOR = 5.17, 95% CI: 1.32–20.4), and moderate pain (AOR = 7.63, 95% CI: 1.811–32.20). Conclusion and recommendation One-third of the study participants had postoperative hyperglycemia. Weight, ASA classification, postoperative body temperature, duration of surgery, intraoperative blood loss, and postoperative pain were identified as a modifiable risk factors. Maintaining normal body temperature throughout the procedure, treating postoperative pain, and monitoring and controlling blood glucose level in patients at risk of hyperglycemia is crucial.

Abstract Background Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively. Purpose This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery. Methods A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy. Results Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R2 = 0.06) Conclusion In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery.

Abstract Background This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA). Methods Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student’s t and Fisher’s exact tests (unadjusted) and multivariable regression (adjusted). Results There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration