Aims. Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA.
We systematically reviewed the published literature
on the complications of closing wedge high tibial osteotomy for
the treatment of unicompartmental osteoarthritis of the knee. Publications
were identified using the Cochrane Library, MEDLINE, EMBASE and
CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled
group clinical (CCTs) trials, case series in publications associated
with closing wedge osteotomy of the tibia in patients with osteoarthritis
of the knee and finally a Cochrane review. Many of these trials
included comparative studies (opening wedge
Introduction. Two-stage exchange arthroplasty remains the gold standard for treatment of PJI with reported success rates of 85–90%.
Aims. Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure. Methods. Between January 2010 and September 2020, 695 rTKAs were performed and data were entered into a prospective database. Inclusion criteria were rTKAs with concomitant TTO, without extensor mechanism allograft, and a minimum of two years’ follow-up. A total of 135 rTKAs were included, with a mean age of 65 years (SD 9.0) and a mean BMI of 29.8 kg/m. 2. (SD 5.7). The most frequent indications for revision were infection (50%; 68/135), aseptic loosening (25%; 34/135), and stiffness (13%; 18/135). Patients had standardized follow-up at six weeks, three months, six months, and annually thereafter.
Introduction. Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. Methods. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors. Results. Smoking was associated with an increased risk of lower respiratory tract infections (LRTI) (4.2% smokers vs. 2.7% non-smokers) (Odds Ratio (OR) 0.76, p-value 0.017). LRTI were similar in ex-smokers & smokers at 3.9%. There was no association with any of the other 6-month complications. Pain medication use over 1-year post surgery was higher in smokers compared to non-smokers: gabapentinoids 7.4% vs. 5.2% (OR 0.74, p< 0.001), opioids 45.9% vs. 35.3% (OR 0.79, p< 0.001), NSAIDs 51.6% vs. 46.1% (OR 0.91, p = 0.044). Mortality was higher in smokers at 1-year compared to non-smokers (hazard ratio (HR) 0.53, p<0.001) & ex-smokers (HR 0.65, p = 0.037), but there was no difference observed at 90-days. There was no association of smoking on revision surgery over 20-years follow up. Smoking was associated with worse postoperative OKS being 3.1 points higher in non-smokers (p<0.001) & 3.0 points higher in ex-smokers (p<0.001). The overall change in OKS before & after surgery was 13.9 points in smokers versus 16.3 points in non-smokers (p<0.001) & 15.7 points in ex-smokers (p<0.001). Over the year following surgery, smokers were more likely to visit their GP, but there was no association with hospital readmission rates. Conclusion. This is the largest study with linked primary care & secondary care data highlighting impact of a preventable patient factor on outcome of a routinely performed planned intervention. Smokers achieved clinical meaningful improvements in patient reported pain & function (OKS) following KA, although their attained post-operative OKS was lower than in non-smokers & ex-smokers. Levels of pain medication use were notably higher in both smokers & ex-smokers. As smokers achieved good clinical outcomes following KA surgery, smoking should not be a barrier to referral for or consideration of KA. However, the study does highlight particular risks a patient is taking if he/she continues to smoke when being considered for elective knee arthroplasty. This study will help the family physicians as well as patients to make an informed decision on whether to go ahead with a planned intervention whilst patient continues to be an active smoker or not. Key Words: Knee Arthroplasty, Smoking, Patient Reported Outcomes, Epidemiology,
End-stage arthropathy is a well-known complication of haemophilia, with recurrent haemarthroses leading to joint destruction, deformity, pain, and stiffness. In the knee, this is often treated with total knee arthroplasty (TKA), which can be more challenging in patients with haemophilia (PwH) and associated with poorer outcomes. We conducted a systematic literature review and meta-analysis to determine implant survivorship, functional outcomes and complication rates. A systematic review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting TKA outcomes with Kaplan-Meier survivorship in PwH (PROSPERO registered). Meta-analysis was performed for survivorship and outcomes, and the results were compared to outcomes from the National Joint Registry (NJR).Abstract
Aim
Method
Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients. We examined the records of 29,270 patients who underwent a primary total joint arthroplasty (TJA), defined as a unilateral total knee arthroplasty (TKA) (18,987) or total hip arthroplasty (THA) (10,283), between 2/2016 and 12/2018 at our institution and identified 338 (242 TKA, 96 THA) patients who developed an in-hospital PE treated with therapeutic anticoagulation. The patients were treated with therapeutic doses of Xa inhibitors, enoxaparin or warfarin. The type and frequency of complications were determined and classified as major or minor. Major complication included: bleeding requiring surgery, GI bleed requiring treatment, >2 unit transfusion and mortality. Minor complications included wound drainage, bleeding not requiring surgery, and thrombocytopenia.Introduction
Methods
Previous research has indicated that preoperative modification of risk factors associated with obesity may reduce complications after TKA. However, the optimal method is still debated. This study aims to investigate whether a preoperative Risk Stratification Tool (RST) devised by our institution to optimize obese patients can reduce unexpected ICU transfers, and 90-day ED visits, readmissions, and reoperations. We retrospectively reviewed 1,724 consecutive risk stratified patients undergoing primary unilateral TKA. The mean age was 64.8 years and average body mass index (BMI) was 34.2 kg/m2. All patients underwent preoperative optimization using the RST. We first compared our primary variables of interest between obese (BMI>30, n=1,189) and non-obese patients (n=535). Patients were then divided into 3 groups (I-non-obese, II-obese (30–39.9 kg/m2) and III-morbidly obese ((>40 kg/m2)) and logistic regression was used to evaluate outcomes among the groups adjusted for age, sex, smoking history and diabetes.Introduction
Methods
We designed this study to compare 30-day complications and length of hospital stay between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal, epidural anesthesia, or Monitored Anesthesia Care (MAC, a combination of local anesthesia with sedation and analgesia provided by an anesthesiologist) with or without regional nerve blocks. We identified patients ≥18 years undergoing TKA between the years of 2006 and 2017 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We collected patient demographics, anesthesia type, 30-day complications, length of operation and hospital stay from the database. We used multivariable regression to compare complications and length of stay (LOS) between anesthesia types, while adjusting for relevant covariablesIntroduction
Methods
Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication.Introduction
Methods
Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m2). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m2 to examine whether this is supported. This single-centre study compared 169 consecutive patients with severe obesity (BMI ≥ 40 kg/m2) (mean age 65.2 years (40 to 87); mean BMI 44.2 kg/m2 (40 to 66); 129/169 female) undergoing unilateral TKA to a propensity score matched (age, sex, preoperative Oxford Knee Score (OKS)) cohort with a BMI < 40 kg/m2 in a 1:1 ratio. Demographic data, comorbidities, and complications to one year were recorded. Preoperative and one-year patient-reported outcome measures (PROMs) were completed: EuroQol five-dimension three-level questionnaire (EQ-5D-3L), OKS, pain, and satisfaction. Using national life expectancy data with obesity correction and the 2020 NHS National Tariff, QALYs (discounted at 3.5%), and direct medical costs accrued over a patient’s lifetime, were calculated. Probabilistic sensitivity analysis (PSA) was used to model variation in cost/QALY for each cohort across 1,000 simulations.Aims
Methods
Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres. mUKAs performed in eight fast-track centres from February 2010 to June 2018 were included from the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Database. All readmissions within 90 days of surgery underwent chart review and readmissions related to the surgical wound or the prosthesis were recorded. Centres were categorized as high-usage centres when using mUKA in ≥ 20% of annual knee arthroplasties. The occurrence of complications between high- and low-usage centres were compared using Fisher’s exact test.Aims
Methods
Revision total knee arthroplasty (revision TKA) occurs for a wide variety of indications and along with revision total hip arthroplasty is billed for using Diagnosis-Related Groups (DRGs) 466, 467, and 468 in the United States. However, DRGs do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision TKA costs and 30-day complications by indication, employing both local granular as well as national standardized databases. Hospitalization costs and complication rates for 1,422 aseptic revision TKAs performed at a high-volume center between 2009 and 2015 were retrospectively reviewed. Additionally, charges for 28,173 revision TKAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios. 30-day complication rates for 3,450 revision TKAs were obtained using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP). Costs and complications were compared between revision TKAs performed for the indication of fracture, wear/loosening, and instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex.Introduction
Methods
There is insufficient data on the trends of anticoagulation after total knee arthroplasty (TKA) in the USA, and the efficacy and safety of rivaroxaban, beyond randomized clinical trials and small cohort studies. Using the Truven Health MarketScan database, we retrospectively evaluated new anticoagulation prescriptions after elective TKA from 2010 to 2015. The frequency of deep vein thrombosis (DVT), pulmonary embolism (PE), and adverse events, within 90 days, were then evaluated in 24,856 new users of warfarin and 21,398 new users of rivaroxaban in commercially insured patients (COM), and 15,483 new users of warfarin and 8,997 new users of rivaroxaban in Medicare supplement patients (MED). Data was analyzed by odds ratios using logistic regression models with stabilized inverse probability treatment weighting.Introduction
Patients and Methods
The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts.Aims
Methods
Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml.Aims
Methods
To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort.Aims
Methods
The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time. A study of 2,393 TKAs was performed in 2,393 patients. Patient demographics, comorbidities, OKS, EuroQol five-dimension score (EQ-5D), and Forgotten Joint Score (FJS) were collected preoperatively and one year postoperatively. Overall patient satisfaction with their TKA was assessed at one year. Patients with VTE within six months of surgery were identified retrospectively and compared with those without.Aims
Methods
The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m2 and ≥ 40 kg/m2 and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses.Aims
Methods
It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes.Aims
Methods