Introduction. Individuals with significant hip and knee trauma receive total knee (TKA) and total hip arthroplasty (THA) as definitive end-stage procedures. In Aotearoa, injury-related costs, including workers compensation, may be funded by ACC. With a steady increase of arthroplasty procedures in Aotearoa, we aim to understand the magnitude and characteristics of such procedures to inform future healthcare strategies. Method. This is a longitudinal collaborative study from 1st January 2000 to 31st December 2020, using ACC and New Zealand Joint Registry databases. Total cost was subcategorised into social and medical cost for analysis. Results. ACC funded 10179 TKA and 5611 THA, amounting to 918 million New Zealand Dollars. Most clients were between 55 and 65 years of age at time of surgery, with greater representation by Male sex and European prioritised ethnicity. Māori and Pacific peoples represent less than 10% of the study population. ACC identified requiring more than 182 days of workers’ compensation as a significant marker for needing additional supports. Risk of this was 21% for TKA and 11% for THA, with risk factors being younger age (RR 0.96), Male sex (TKA RR 1.12, THA RR 1.23), and heavy work-types (TKA RR 1.50, THA RR 1.57). Discussion. Supporting individuals with post-traumatic lower limb arthroplasty is costly. Workers’ compensation contributes to a significant proportion of social expenditure. Risk factors for increased cost utilisation can be used to highlight vulnerable clients and target interventions. Conclusions. This is one of few nationwide studies investigating the healthcare cost of post-traumatic lower limb arthroplasty. We need to focus on injury prevention, targeted treatment, and rehabilitation protocols to improve recovery and reduce time off work. These findings would be of interest to multiple stakeholders

Aims

Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections.

The February 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Trial of vancomycin and cefazolin as surgical prophylaxis in arthroplasty; Is preoperative posterior femoral neck tilt a risk factor for fixation failure? Cemented versus uncemented hemiarthroplasty for displaced intracapsular fractures of the hip; Periprosthetic fractures in larger hydroxyapatite-coated stems: are collared stems a better alternative for total hip arthroplasty?; Postoperative periprosthetic fracture following hip arthroplasty with a polished taper slip versus composite beam stem; Is oral tranexamic acid as good as intravenous?; Stem design and the risk of early periprosthetic femur fractures following THA in elderly patients; Does powered femoral broaching compromise patient safety in total hip arthroplasty?

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery. A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals. Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who . were. vs . were not. using opioids pre-operatively (respectively); acute adverse events (39.1% vs 38.6%), acute significant adverse events (5.3% vs 5.7%), late adverse events: (6.9% vs 6.6%), total significant adverse events: (12.5% vs 12.4%), discharge to inpatient rehab (86.4% vs 88.6%), length of hospital stay (5.9 (3.0) vs 5.6 (3.0) days), 6-month post-op Oxford Score (38.8 (8.9) vs 39.5 (7.9)), 6 months post-op EQ-VAS (71.7 (20.2) vs 76.7 (18.2), p<0.001), success post-op described as “much better” (80.2% vs 81.3%). Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes. Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events

Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients’ performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.

Cite this article: Bone Joint J 2022;104-B(10):1104–1109.

Aims

The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA).

Aims

Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI.

Aims

Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT).

Aims

The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services.

Aims

The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.

Background. The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings. Methods. Using our institution's data, we calculated the mean cost per episode of care. We calculated the percent reduction in target price and percent savings or losses per case for the CJR and Bundle Payment Care Initiative (BPCI) for each Medicare Severity Diagnosis Related Group (MS-DRG) using mean cost per episode and CJR and BPCI target prices. We compared the target prices, annual savings, and losses per episode of care for both CJR and BPCI. All CJR savings, projected and actual, were computed by comparing CJR savings to that of 2018 BPCI savings. Results. We found an average savings of 2.32% under CJR compared to the projected loss of −11.6% for MS-DRG 469 with fracture. There was a 7.97% savings for MS-DRG 470 without fracture compared to the projected 1.9%, a 20.94% savings for MS-DRG 470 with fracture compared to the projected 23.7%, and a loss of −3.98% for MS-DRG 469 without fracture compared to the projected 2.5% savings. Conclusions. The CJR target prices are lower than that of BPCI and this makes maintaining an episode of care at or below the target price increasingly difficult. Discharge disposition and readmission are well established factors that increase hospital cost [7]. However, reduction of these does not seem enough to maintain savings under the CJR model. New cost savings mechanisms such as identification of patients eligible for SDD, and reduction of unnecessary home services resulted in smaller losses of positive margins, though these were still significantly less for CJR than BPCI

Objectives

Prosthetic joint infection (PJI) is the most common cause of arthroplasty failure. However, infection is often difficult to detect by conventional bacterial cultures, for which false-negative rates are 23% to 35%. In contrast, 16S rRNA metagenomics has been shown to quantitatively detect unculturable, unsuspected, and unviable pathogens. In this study, we investigated the use of 16S rRNA metagenomics for detection of bacterial pathogens in synovial fluid (SF) from patients with hip or knee PJI.

Introduction. Despite several preventive strategies, periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is still a devastating complication. Early diagnosis and appropriate treatment are crucial to achieve successful infection control, but challenging since there is no test with 100% sensitivity and 100%. Therefore, several national and international guidelines include synovial analysis of joint aspirates as important diagnostic criteria, but cut-off levels for synovial cell count (CC) and polymorphonuclear (granulocyte) percentage (PMN%) are still debatable. The current investigation was performed to analyze the overall accuracy and optimal cut-off of synovial CC and PMN% following total knee (TKA) and total hip arthroplasty (THA). Methods. Between October 2012 and June 2017, all patients with painful TKA or THA, who underwent joint aspiration before revision arthroplasty were included in this retrospective study. From aspirated synovial fluid, leukocyte esterase activity, leukocyte CC and PMN% were determined, and specimens were sent for bacterial culture. A total of 524 preoperative joint aspirations (255 hips, 269 knees) were enrolled for final analysis. For 337 patients, the synovial CC and PMN% could be measured by the laboratory. From those patients, 203 patients were scheduled for aseptic revision, and 134 patients for septic revision arthroplasty according to the MSIS criteria for PJI. Specificity (SP), sensitivity (SE), positive predictive value (PPV), negative predictive and overall accuracy were measured for CC and PMN%. The optimum cut-off value was calculated by the ROC and the value giving the AUC, achieving the best possible level of sensitivity and specificity. Results. The best cut-off level for PJI of all study patients was 2582 leukocytes/μL (Se 80.6%, Sp 85.2%) and a PMN% of 66.1% (Se 80.6%, Sp 83.3%). The chosen cut-off levels for PJI of TKA was 1630 leukocytes/μL (Se 83.6%, Sp 82.2%) and a PMN% of 60.5% (Se 80.3%, Sp 77.1%). The optimal cut-off values for PJI of THA was 3063 leukocytes/μL (Se 78.1%, Sp 80.0%) and a PMN% of 66.1% (Se 82.2%, Sp 82.4%). Conclusions. Synovial cell count and polymorphonuclear percentage are sensitive methods for diagnosing PJI with differences in cut-off levels for THA and TKA. We suggest considering the cut-off levels of CC and PMN% from aspirates of TKA at 1600/μL and 60%, respectively, as possible PJI. For THA, the cut-off levels of CC and PMN% are at 3000/μL and 66%, respectively

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

The entirety of the patient experience after contemporary total knee and total hip replacements in 2017 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some include gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

We live in an era where younger, fitter, more active patients are presenting with the symptoms and signs of degenerative joint disease and require total knee and total hip arthroplasty at a young age. At the same time, this population of patients is living longer and longer and is likely to create new and more complex failure modes for their implants. The ideal solution is a biological one, whereby we can either prevent joint degradation or catch it in its early stages and avoid further deterioration. There may also be advances along the way in terms of partial arthroplasty and focal resurfacing that will help us prevent the need for total joint arthroplasty. There are several tensions that need to be considered. Should we resurface / replace early, particularly now that we have access to navigation and robotics and can effectively customise the implants to the patient's anatomy and their gait pattern? This would allow good function at a young age. Or should we wait as long as possible and risk losing some function for the sake of preserving the first arthroplasty for the lifetime of the patient?. There are some key issues that we still do not fully understand. The lack of true follow-up data beyond 20 or 30 years is worrying. The data available tends to be from expert centers, and always has a dramatic loss to follow-up rate. We worry about bearing surfaces and how those materials will behave over time but we really do not know the effect of chronic metal exposure over several decades, nor do we really understand what happens to bone as it becomes more and more osteopenic and fragile around implants. We have largely recorded but ignored stress shielding, whereas this may become a very significant issue as our patients get older, more fragile, more sarcopaenic and more neurologically challenged. All the fixation debates that we have grappled with, may yet come back to the fore. Can ingrowth lead to failure problems later on? Will more flexible surfaces and materials be required to fit in with the elasticity of bone?. We have failed dramatically at translating the in vitro to the in vivo model. It seems that the in vitro model tells us when failure is going to occur but success in vitro does not predict success in vivo. We, therefore, cannot assume that long-term wear data from simulators will necessarily translate to the extreme situations in vivo where the loading is not always idealised, and can create adverse conditions. We must, therefore, consider further how to improve and enhance our interventions. There is no doubt that the avoidance of arthroplasty needs to be at the heart of our thinking but, ultimately, if arthroplasty is to be performed, it needs to be performed expertly and in such a way as to minimise later failure. It also, clearly, needs to be cost-effective. The next stage will no doubt involve close cooperation between surgeons, engineers and industry partners to identify individualised surgical targets, select an appropriate prosthesis to minimise soft-tissue strain and develop a reproducible method of achieving accurate implantation. An ideal outcome can only be achieved by an appropriately trained surgeon selecting the optimal prosthesis to implant in the correct position in the well-selected patient. In the longer term, our choice of implants and the way that they are inserted and fixed must take into account the evolving physiology of our patients, the nature of our devices and how to limit harm from them, and the long-term impact of the materials used which we sometimes still do not understand

Objectives

The primary aim of this study was to assess the reproducibility of the recalled preoperative Oxford Hip Score (OHS) and Oxford Knee Score (OKS) one year following arthroplasty for a cohort of patients. The secondary aim was to assess the reliability of a patient’s recollection of their own preoperative OHS and OKS one year following surgery.

Aim. Periprosthetic joint infection (PJI) is nowadays the most important problem leading to failure in primary and revision total knee (TKA) and total hip arthroplasty (THA), therefore accurate diagnosis of PJI is necessary. We evaluated a commercial multiplex PCR system1 for diagnosis of PJI in joint aspiration fluids prior to surgery. Method. A total of 32 patients were included in the study. Twenty-four patients had TKA and eight had THA. Joint aspiration fluids were examined by standard bacteriological procedures. Excess material of joint aspirates was frozen at −20°C until testing by multiplex PCR1. Inclusion criteria were a minimum leucocyte count of 2.000 per ml and at least 60% of polymorphonucleaur neutrophils (PNN) in the joint aspiration fluid. Results. For 21 patients with TKA, both standard bacteriological culture and PCR1 were negative. In these patients the mean leucocyte count in the joint fluid was 15.385/ml with 80% PNN. For three patients culture was negative, but PCR1 was positive. In one patient PCR1 detected Corynebacterium sp. which was considered as contamination as this patient had crystal arthropathy; for the second patient Propionibacterium acnes was detected by PCR1, this patient was treated as having an infection of unknown origin in another hospital. For the third patient PCR1 detected Pseudomonas aeruginosa. This patient was known as having chronic P. aeruginosa infection of his TKA and joint aspiration was done shortly after arrest of antibiotic therapy by ciprofloxacin. The mean leucocyte count in the patients with positive PCR was 61.800/ml with 89% PNN. In three of the eight patients with THA, standard bacterial culture and PCR1 were both negative. The mean leucocyte count in joint aspirates of these patients was 10.087/ml with 77% PNN. In five patients with THA, both culture and PCR1 were positive and concordant. In one case culture and PCR1 detected Staphylococcus aureus, and in the other culture and PCR1 detected P. acnes. In two cases culture grew S. epidermidis and PCR1 detected coagulase negative Staphylococcus. In the fifth patient culture grew C. jeikeium and PCR1 detected Corynebacterium spp. Conclusions. We found concordant results for culture and PCR1 in all eight patients with THA and in 22/24 patients (92%) with TKA. Multiplex PCR1 results are available in 4 hours whereas culture results may demand several days. The commercial multiplex PCR system1 designed for diagnosis of implant and tissue infection can be helpful for the diagnosis of PJI. *Unyvero i60©, Curetis Strasbourg, France