David Mitchell

Background: Non‐steroidal anti‐inflammatory drugs (NSAIDs) are fundamental for multimodal analgesic therapy, but are traditionally avoided in renally impaired patients. We aim to show NSAIDs can be safely administered to arthroplasty patients with a pre‐operative estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m² without causing a permanent reduction in post‐operative eGFR and, in doing so, minimise opioid use.Methods: We prospectively collected data from patients with a pre‐operative eGFR less than 60 mL/min/1.73 m² undergoing arthroplasty between January 2018 and June 2023 at St John of God Ballarat Hospital, Australia. Baseline eGFR was obtained pre‐operatively, and on at least 1 of days 1, 2, 10, or a follow‐up review appointment of at least 4 weeks. Patients received tailored dosing of perioperative NSAIDs corresponding to pre‐operative eGFR. Acute kidney injury (AKI) was defined using the RIFLE criteria.Results: We identified 221 patients. Median baseline eGFR was 50 mL/min/1.73 m² and median eGFR recovery at latest follow‐up was 109% of baseline eGFR. 28% of the cohort had a clinically significant reduction in eGFR on day 1 post‐operatively, and by latest follow‐up, this subgroup had a median recovery of 106% of baseline eGFR. At the 2‐week follow‐up, there were no cases of AKI, and by latest follow‐up, no patients had a clinically significant reduction of baseline eGFR.Conclusion: Perioperative NSAIDs in renally impaired patients undergoing arthroplasty surgery can be safely given using an adjusted dose protocol based on pre‐operative renal function. Future studies investigating the circumspect use of NSAIDs for pain management during arthroplasty are warranted.

(1) Background: Bone healing is influenced by various mechanical factors, such as stability, interfragmentary motion, strain rate, and direction of loading. Far cortical locking (FCL) is a novel screw design that promotes bone healing through controlled fracture motion. (2) Methods: This study compared the outcome of distal femur fractures treated with FCL or SL (standard locking) screws and an NCB plate in a randomised controlled prospective multicentre trial. The radiographic union scale (RUST) and healing time was used to quantify bone healing on follow-up imaging. (3) Results: The study included 21 patients with distal femur fractures, 7 treated with SL and 14 treated with FCL screws. The mean working length for patients with SL screws was 6.1, whereas for FCL screws, it was 3.9. The mean RUST score at 6 months post fracture was 8.0 for patients with SL plates and 7.3 for patients with FCL plates (p value > 0.05). The mean healing time was 6.5 months for patients with SL plates and 9.9 months for patients with FCL plates (p value < 0.05). (4) Conclusions: Fractures fixed with SL plates had longer working lengths and faster healing times when compared to FCL constructs, suggesting that an adequate working length is important for fracture healing regardless of screw choice.

Multimodal therapy (MMT) for analgesia following joint arthroplasty continues to reduce cost and the requirement of strong opioids post-operatively. Tramadol immediate release is an important MMT component providing synergistic pain relief via dual μ-opioid agonism and serotonin and noradrenaline reuptake inhibition. Case reports have shown tramadol when combined with antidepressants cause serotonin syndrome, but this has yet to be demonstrated in larger studies. We undertook a pilot study assessing the functional outcomes and incidence of side effects associated with tramadol in lower limb arthroplasty patients with a focus on those taking concomitant antidepressants. Primary and revision hip and knee arthroplasties performed in 2018-2019 by a senior surgeon were included (n = 364). Patient records were assessed to determine pain scores, length of hospitalization, prescription of tramadol and antidepressants, self-reported side effects and previous adverse reactions associated with tramadol. Nine-five percentage of patients had been prescribed tramadol, and 16% had concurrent prescription of tramadol and one or more antidepressants. The total rate of adverse effects associated with tramadol before and during the study was 7% (n = 25) including two cases of concomitant tramadol and antidepressant use. For patients on tramadol, median 2-week post-operative pain score was 1.5 (IQR 1-2.5) out of 10 and hospitalization length was 1 (IQR 1-2) days. Tramadol immediate release appears to be well tolerated among our patient population with no significantly increased prevalence of side effects when co-administered with low and moderate dose antidepressants.

Background: Osteoarthritis of the knee is a chronic inflammatory condition resulting in significant patient disability, with intra‐articular platelet rich plasma (PRP) injections having shown potential to improve symptomatic outcomes. This retrospective cohort pilot study aimed to observe whether PRP injections were beneficial in the symptomatic management of knee osteoarthritis in an Australian population, based on patient reported outcomes. An additional aim was to observe for an association between the number of injections and patient characteristics, such as body mass index, age, sex and radiologically determined severity of the disease.Methods: The cohort was drawn from those who attended Ballarat Orthopaedic and Sports Medicine for PRP injections and who had completed the appropriate pre‐ and post‐injection Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. WOMAC scores were analysed to observe for any difference following a course of PRP injections.Results: The data suggest that the use of PRP improved patient reported WOMAC scores. Additionally, it was shown that two injections had a greater effect than one injection, with a third injection providing no further benefit. Finally, there was an association with lower WOMAC scores post PRP therapy amongst male participants compared to female participants.Conclusion: These results suggest two PRP injections are optimal for the symptomatic management of knee osteoarthritis, identifying a need for further prospective research in this Australian population.

Background: We implemented local infiltration analgesia (LIA) as a technique of providing post‐operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery.Methods: Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost.Results: Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505.Conclusion: The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.