The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups.Aims
Methods
Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR. Four interconnected work packages have recently been completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from four national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty.
For ODEP10A∗ minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review For ODEP10A∗ minimum implants in complex cases, or non-ODEP10A∗ minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment; ongoing rapid access to orthopaedic review is still required These recommendations apply to post primary hip and knee replacement follow-up The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure
Overarching statements
Open fractures are common, and infection a frequent complication. There is still uncertainty regarding the urgency of initial treatment. The majority of animal studies indicate that early irrigation and debridement reduces infection; unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the infection rate. These studies are observational and fraught with confounding variables. The purpose of this study was to control for these variables using an animal model incorporating both systemic antibiotics and surgical treatment. This study used a segmental defect rat femur model contaminated with Staphylococcus aureus and treated with a 3 day course of systemic cefazolin (5 mg/Kg 12 hourly) and surgical treatments, both of which were initiated independently at 2, 6 and 24 hour time points. After 14 days bone and hardware was harvested for separate microbiological analysis. These results show that the earlier systemic antibiotic treatment or surgery is initiated. When antibiotics are started at 2 hours, delaying surgical treatment from 2 to 6 hours significantly increases infection (p=0.047). However, delaying surgery to 24 hours increases infection, but not significantly (p=0.054). The timing of antibiotics had a more significant effect on the proportion of positive samples than earlier surgery. At the 2 and 6 hour treatments, the p value was 0.004 and for the 6 and 24 timings it was 0.003. Surgery and antibiotics at 2 hours completely eradicates the bacteria, but surgical delay for 6 hours appears to allow the bacteria to form non-susceptible colonies. Delaying antibiotics to 6 or 24 hours had a profound detrimental effect on the infection rate regardless of timing of surgery. These findings are consistent with the concept that bacteria progress from a vulnerable planktonic form to a treatment-resistant biofilm.
