Aims. The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC. Methods. Among a single-surgeon cohort of 970 patients who underwent arthroplasty at an ASC, 854 (88.0%) were matched one-to-one with inpatients based on age, sex, American Society of Anesthesiologists (ASA) grade, BMI, and procedure (105 could not be adequately matched and 11 lacked 90-day follow-up). The cohort included 281 total hip arthroplasties (THAs) (32.9%), 267 unicompartmental knee arthroplasties (31.3%), 242 primary total knee arthroplasties (TKAs) (28.3%), 60 hip resurfacings (7.0%), two revision THAs (0.3%), and two revision TKAs (0.3%). Outcomes included readmissions, reoperations, visits to the emergency department, unplanned clinic visits, and complications. Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The reoperation rate was 0.9% in both cohorts (p = 1.000). Rates of readmission (2.0% inpatient vs 1.6% outpatient), any complications (5.9% vs 5.6%), minor complications (4.2% vs 3.9%), visits to the emergency department (2.7% vs 1.4%), and unplanned clinic visits (5.7% vs 5.5%) were lower in the outpatient group but did not reach significance with the sample size studied. A learning curve may exist, as seen by significant reductions in the reoperation and overall complication rates among outpatient arthroplasties over time (p = 0.032 and p = 0.007, respectively), despite those in this group becoming significantly older and heavier (both p < 0.001) during the study period. Conclusion. Arthroplasties performed at ASCs appear to be safe in appropriately selected patients, but may be associated with a learning curve as shown by the significant decrease in complication and reoperation rates during the study period. Cite this article: Bone Joint J 2021;103-B(7 Supple B):84–90

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Introduction. The proportion of arthroplasties performed in the ambulatory setting has increased substantially. However, concerns remain regarding whether same-day discharge may increase the risk of complications. The purpose of this study was to compare 90-day outcomes between inpatients and patients having surgery at an ambulatory surgery center (ASC). Methods. Among a single-surgeon cohort of 721 patients who underwent arthroplasty at a free-standing ASC, 611 (84.7%) were matched one-to-one to inpatients based on age, gender, American Society of Anesthesiologists (ASA) score, and Body Mass Index (110 patients could not be adequately matched). The cohort included 208 total hip arthroplasties (34.0%), 196 total knee arthroplasties (32.1%), 178 unicompartmental knee arthroplasties (29.1%), 25 hip resurfacings (4.1%), two revision hip arthroplasties (0.3%) and two revision knee arthroplasties (0.3%). Post-operative outcomes including readmissions, reoperations, unplanned clinic visits, emergency department visits, and complications were compared. Complications were classified as either major (i.e. death, periprosthetic joint infection, pulmonary embolism) or as minor (i.e. delayed wound healing, rashes, urinary retention). Results. The inpatient and outpatient groups were similar in all demographic variables, reflecting successful matching. The rates of any complications (4.1% outpatient vs. 5.1% inpatient, p=0.41), minor complications (2.6% vs. 3.4%; p=0.40), readmissions (1.6% vs. 2.0%; p= 0.67), reoperations (0.7% vs. 1.1%; p=0.36), and unplanned clinic visits (5.4% vs 6.7%; p=0.34) were all lower amongst the outpatient group but did not reach significance with the sample size studied. The rate of major complications was the same in both groups (1.6% for both; p=1.0) while patients who underwent surgery at an ASC had significantly fewer emergency department visits (1.0% vs. 3.1%; p=0.009). Conclusions. Arthroplasty performed in the ambulatory setting appears to be safe in properly selected patients. However, this finding may be partly due to selection bias and intangible characteristics that were not adequately controlled for through matching

Aims. Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods. This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results. A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion. Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. Cite this article: Bone Jt Open 2023;4(6):447–456

Whilst total hip replacement (THR) is generally safe and effective, pre-existing medical conditions, particularly those requiring inpatient admission, may increase the risk of post-operative mortality. Delaying elective surgery may reduce the risk, but it is unclear how long a delay is sufficient. We analysed 958,145 primary THRs performed for solely osteoarthritis April 2003-December 2018, in the NJR linked to Hospital Episodes Statistics to identify inpatient admissions prior to elective THR for 17 conditions making up the Charlson index including myocardial infarction, congestive heart failure, cerebrovascular disease and diabetes. Crude analyses used Kaplan-Meier and adjusted analyses used Cox modelling. Patients were categorised for each co-morbidity into one of four groups: not recorded in previous five-years, recorded between five-years and six-months before THR, recorded six-months to three-months before THR, and recorded between three-months and day before surgery. 90-day mortality was 0.34% (95%CI: 0.33–0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed 63 times increased hazard of death within 90-days if patients had an acute MI in the 3-months before their THR, compared to patients who had not had an MI in the five years before their THR (HR 63.6 (95%CI 50.8, 79.7)) This association reduced as the time between acute MI and THR increased. For congestive cardiac failure, the hazard in the same scenario was 18-times higher with a similar protective effect of delaying surgery. Linked NJR and HES data demonstrate an association between inpatient admission for acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the admission for acute medical conditions and THR in all diagnoses. This information will help patients with previous medical admissions and surgeons to determine optimal timing for surgery

Summary. Narcotic administration within the inpatient setting is highly variable any may benefit from the implementation of standardized multi-modal pain management protocols. Introduction. Total joint arthroplasty (TJA) candidates have historically received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid prescribing documentation and implementing narcotic-sparing pain protocols into TJA integrate care pathways (ICP). Despite these efforts, there are few technological platforms designed to curtail excessive inpatient narcotic administration. Here we present an early iteration of an inpatient narcotic administration reporting tool which normalizes patient narcotic consumption as an average daily morphine milligram equivalence (MME) per surgical encounter (MME/day/encounter) among total hip arthroplasty (THA) recipients. This information may help orthopaedic surgeons visualize their individual granular inpatient narcotic prescribing habits individually and compared to other surgeons, while taking into consideration patient and procedure specific variables. Material and Methods. A query of our electronic data warehouse, was performed for patients undergoing elective primary THA between January 1, 2016 to April 30, 2017. Patient demographics; inpatient and surgical factors; and inpatient narcotic administration were retrieved. Narcotic type, route and dose were converted into total Morphine Milligram Equivalences (MMEs;) on a patient encounter basis (MME/day/encounter). MME/day/encounter were subsequently used determine mean and variance of narcotics prescribed by healthcare providers. A secondary analysis of regional distribution of inpatient narcotic consumption was determined by patient's zip codes. Results. In total, 4020 primary THAs were included. The institutional average narcotic dose administered for a single surgical encounter was 24.44±52.09 MME/day/encounter. Average surgeon narcotic prescribing ranged from 13.02 to 40.70 MME/day/encounter. Similarly, intra-surgeon variability of narcotic prescribing habits varied from ±21.24 to ±91.94 MME/day/encounter. Further evaluation of patient breakdown did not demonstrate a trend towards increased narcotic administration or variability for surgeons when compared to patient race or insurance type. Moreover, regional distribution of narcotic administration appeared to visually correlate with median household income, whereby less affluent areas demonstrated increased MME/day/encounter. Discussion. Narcotic administration in the inpatient setting among orthopaedic surgeons at the same academic institution is highly variable as evidenced by the differences in mean MME/day/encounter. Although patient and operative characteristics may vary among THA recipients a more comprehensive understanding of narcotic prescribing patterns may enable healthcare organizations to develop multimodal pain management pathways tailored to the patient's needs

The purpose of our study is to examine the outcome of patients undergoing outpatient total hip arthroplasty with a BMI >35. Case-control matching on age, gender (46% female;54%male), and ASA (mean 2.8) with 51 outpatients BMI≥35 kg/m. 2. (mean of 40 (35–55)), mean age of 61 (38–78) matched to 51 outpatients BMI<35 kg/m. 2. (mean of 27 (17–34)) mean age 61 (33–78). Subsequently 47 inpatients BMI≥35 kg/m. 2. (mean of 40 (35–55)) mean age 62 (34–77) were matched outpatients BMI≥35 kg/m. 2. For each cohort, adverse events, readmission in 90 days, reoperations were recorded. Rate of adverse events was significantly higher in BMI ≥35: 15.69% verus 1.96% (p=0.039) with 5 reoperations in the BMI≥35 cohort vs 0 in the BMI<35 kg/m. 2. (p= 0.063). Readmissions did not differ between groups (p=0.125). No significant difference for all studied outcomes between the outpatient and inpatients cohorts with BMI≥35 kg/m. 2. The most complications requiring surgery/medical intervention (3B) were in the inpatient cohort of patients >35. The prevalence of Diabetes and Obstructive Sleep apnea was 21.6% and 29.4% for BMI>35 compared to 9.8% and 11.8%, for BMI <35, respectively. Severely obese patients have an overall higher rate of adverse events and reoperations however it should not be used a sole variable for deciding if the patient should be admitted or not

Aims. High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. Methods. A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI. Results. Mean operating time increased with BMI and for BMI > 50 kg/m. 2. was approximately twice that of BMI 10 kg/m. 2. to 15 kg/m. 2. Mean inpatient cost did not vary significantly with BMI. Mean total reimbursement was lowest for the lowest BMI cohort and increased with BMI. Mean LOS was greatest at the extremes of BMI (4.0 days for BMI 10 kg/m. 2. to 15 kg/m. 2. ; 3.75 days for BMI > 50 kg/m. 2. ) and twice that of normal BMI. Mean complication rates were greatest in the lowest BMI cohort (16% for BMI 10 kg/m. 2. to 15 kg/m. 2. ) and five times the mean rate of complications in the normal BMI cohorts. Furthermore, 30-day readmissions were greatest in the highest BMI cohort (10% for BMI > 50 kg/m. 2. ) and five times the rate for normal BMI patients. Conclusion. LOS, complications, and 30-day readmissions all increase at the extremes of BMI and appear to be greater than those of patients with normal BMI. The lowest BMI patients had the lowest payment for inpatient stay yet were at considerable risk for complications and readmission. Patients with extreme BMI should be counselled about their increased risk of complications for THA and nutritional status/obesity optimized preoperatively if possible. Cite this article: Bone Joint J 2020;102-B(7 Supple B):62–70

Introduction. Total hip arthroplasty (THA) is an effective surgery for the treatment of advanced osteoarthritis but increasing numbers of these procedures are having a significant impact on healthcare budgets. One route to mitigate the increasing costs is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to determine the cost of outpatient THA compared to standard overnight stay in hospital. Methods. This was a prospective-randomized controlled trial for patients undergoing primary THA through a direct anterior approach. Participants were randomized to be discharged on the same day as surgery, as outpatients, or on day one post-surgery, as inpatients, using a Zelen consent model. Adverse events were assessed, and participants completed self-reported cost questionnaires at two-, six- and 12-weeks post-surgery, and the WOMAC preoperatively and at 12-weeks post-surgery. We performed a cost analysis from health care payer (HCP) and societal perspectives. Results. 106 patients were enrolled in this study, with 50 randomized to outpatient and 56 randomized to inpatient THA. Seven patients from the outpatient group and five patients from the inpatient group crossed-over. Adverse event rate was similar between the groups with seven events in four participants in the inpatient group and three events in two participants in the outpatient group. WOMAC scores were not significantly different between the groups (p=0.12). From both a HCP and societal perspective, inpatient THA was more costly than outpatient THA. The cost difference was $3,353.15 for HCP (p<0.0001) and $3,703.30 for societal (p=0.003) in favour of outpatient THA. Conclusion. Our results suggest that outpatient THA is a cost-saving procedure when compared to inpatient THA from both HCP and societal perspectives. We will continue recruitment to investigate whether these results hold true in a larger sample as well as assess for cost-effectiveness, patient safety and satisfaction. Acknowledgements. This study was supported by the Opportunities Fund of the Academic Health Sciences Centre Alternative Funding Plan of the Academic Medical Organization of Southwestern Ontario (AMOSO). We also received funding from the PSI Foundation. For any tables or figures, please contact the authors directly

Post-operative periprosthetic fracture of the femur (POPFF) is a growing problem associated with increased mortality. Most registry derived estimates of mortality only record patients who undergo revision and cohort studies are generally limited to a single center, which makes comparison for the purposes of service improvement difficult. The aim of this study is to perform a systematic review and meta-analysis of cohort studies reporting mortality following POPFF in the last decade. Study methodology was peer-reviewed (PROSPERO: CRD42020170819). Literature search was conducted using Medline and EMBASE. Primary exposure was the diagnosis of POPFF, and the primary outcome measure was all-cause mortality: whilst an inpatient, within 30-days, within 90-days and within one year of POPFF. Proportion of patients dying (95% CI [confidence interval]) was estimated using metaregression. Results were compared to mortality following neck of femur fracture (NOF) from international NOF registry data. 4841 patients from 35 cohort studies were included. Study quality was generally low with a majority limited to a single centre. Weighted mean follow-up was 2.3 years and the most common POPFF was UCS B. Pooled proportion dying as an inpatient was 2.4% (95% CI 1.6% to 3.4%). Pooled proportion dying within 30 days was 3.3% (95% CI 2.0% to 5.0%). Pooled proportion dying within 90 days was 4.8% (95% CI 3.6% to 6.1%). Pooled proportion dying within one year was 13.4% (95% CI 11.9% to 14.8%). Mortality following POPFF was similar to that of NOF up to 30 days, but better at one year. 3.3% of patients die following POPFF within 30 days of injury. Mortality is similar to that experienced by patients following NOF up to 30 days, but better at one year, which may represent the lower underlying risk of death in the POPFF cohort. These results may form the basis for evaluation of services treating POPFF in the future

Within an ageing population, the morbidity and mortality burden of neck of femur fractures will only worsen. Financially incentivising acute Trusts via the Best Practice Tariff for inpatient care has yielded good results(1,2,3,4) but post-discharge care is still variable. Most importantly, restoring patients to their pre-fracture mobility is key to their quality of life(5,6) and reducing both readmissions to hospital(7,8) and expensive local authority residential care. Unfortunately, physiotherapist vacancies are in their thousands(9,10) leading to waiting times of around three months once discharged(11). In 2019, the Royal Derby Hospital created a novel Hip Fracture Patient Advocate (HFPA) to observe those who have fallen through gaps in community services. It involves monitoring patients’ progression, signposting to appropriate services, flagging issues to the responsible consultant and assisting in physical mobilisation. A retrospective review examined data from patients discharged to their own homes. This included demographics, residential status and mobility, both pre-fracture and at 120 days post-fracture. Mobility was classified into five categories, in line with the national hip fracture database. In 2018, of 238 patients, 41.2% returned to their baseline or increased mobility, and, after the introduction of the HFPA in 2019, this figure increased to 48.2%. In one year, there was a 7% increase in patients recovering their baseline mobility. This is a cost-effective intervention that can successfully improve mobility, leading to improved long-term outcomes. This includes the potential to reduce acute readmissions and the need for residential care, appealing to Integrated Care Boards. It also bridges the gap to primary care to optimise medical management and after further development, could be financially-incentivised via the Best Practice Tariff. Rather than thinking more expensive clinicians are required, this study proposes that a HFPA can garner better outcomes for both the patient and the wider system

We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine post-operative blood tests, estimated at over £1.6m per year. Elective activity over winter was significantly higher (79%) than in the same time period in the previous year. An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS

Total Hip Arthroplasty (THA) and Hip Hemiarthroplasties (HA) are successful, cost-effective procedures that improve quality of life. Dislocation is a well recognised complication with a significant health and economic burden. We aim to establish the current management practices across the United Kingdom (UK) for Prosthetic Hip Dislocations (PHD). Our definition of a PHD includes; THA, HA and revision THA. This national study builds on our regional pilot study and records one of the largest datasets of Prosthetic Hip Dislocation management within the UK. A trainee-led collaborative; the North West Orthopaedic Research Collaborative (NWORC). Conducted a retrospective audit, registered as Quality Improvement (QI) projects, collected data from 38 hospital trusts across the UK. Data was collected on patient-related factors, inpatient management, and outpatient follow up of each PHD episode between January and July 2019. Primary outcome measured definitive management, in the form of revision surgery or the consideration for this through a referral pathway. A total of 673 (THA 504, Revision THA 141, HA 28) patients were included with a total of 740 dislocation episodes. Mean age was 75.6 years with female to male ratio 2:1. The majority of PHDs were a result of a low energy mechanism (98.7%) and presented over 6 months post index procedure (80.5%). Over half (53.8%) attended with a first or second time dislocation. Only 29.9% patients received onward revision referral; whereas 70.1% followed diverse management patterns, including local non-arthroplasty and primary arthroplasty surgeon follow-ups. Revision THAs had higher rates of referral for revision (p<0.001) compared to primary THA and HA dislocations. A high number of PHDs present across the UK, with under a third receiving definitive management plans. This variation increases the economical burden to the National Health Service, highlighting the need for national guidance to manage these complex patients

The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

Two-stage exchange arthroplasty is traditionally used to treat periprosthetic hip infection. Nevertheless, particularly in high-risk patients, there has been increased attention towards alternatives such as 1.5-stage exchange arthroplasty which takes place in one surgery. Therefore, we sought to compare (1) operative time, length-of-stay (LOS), transfusions, (2) causative organism identification and polymicrobial infection rates, (3) re-revision rates and re-revision reasons, (4) mortality, and determine (5) independent predictors of re-revision. Retrospective chart review of 71 patients who underwent either 1.5- (n=38) or 2-stage (n=33) exchange hip arthroplasty at a single institution (03/2019-05/2023). Demographics, surgical, inpatient, and infection characteristics were noted. Main outcomes evaluated were re-revision rates, re-revision reasons, mortality, and cause of death. Independent predictors of re-revision were assessed utilizing logistic regression. Mean follow: 675 days (range, 23–1,715). Demographics were not significantly different except for a higher proportion of 1.5-stage patients classified as American-Society-of-Anesthesiologists (ASA) status 3 or 4 (84.2 vs. 48.5%, p=0.002). Length of follow-up was significantly longer in the 2-stage group (924.4 vs. 458 days, p<0.001) as well as operative time (506 vs. 271 minutes, p<0.001). In the 1.5-stage group, there was a higher proportion of polymicrobial infections (23.7 vs. 3.0%, p=0.016), re-revision rates (28.9 vs. 9.1%, p=0.042) and periprosthetic infections as a cause of revision (90.9 vs. 0%, p=0.007). Mortality rates were not significantly different, and no patient died for causes related to infection. Type of surgery (1.5-stage vs. 2-stage) was the only independent predictor of re-revision (odds-ratio 4.0, 95% confidence-interval 1.02–16.16, p=0.046). Our data suggests that patients who undergo 1.5-stage exchange arthroplasty have a significantly higher re-revision rate (mostly due to infection) when compared to 2-stage patients. We acknowledge potential benefits of the 1.5-stage strategy, especially in high-risk patients since it involves single surgery. However, higher re-revision rates must be considered when counseling patients

Aims. The current study aimed to compare robotic arm-assisted (RA-THA), computer-assisted (CA-THA), and manual (M-THA) total hip arthroplasty regarding in-hospital metrics including length of stay (LOS), discharge disposition, in-hospital complications, and cost of RA-THA versus M-THA and CA-THA versus M-THA, as well as trends in use and uptake over a ten-year period, and future projections of uptake and use of RA-THA and CA-THA. Methods. The National Inpatient Sample was queried for primary THAs (2008 to 2017) which were categorized into RA-THA, CA-THA, and M-THA. Past and projected use, demographic characteristics distribution, income, type of insurance, location, and healthcare setting were compared among the three cohorts. In-hospital complications, LOS, discharge disposition, and in-hospital costs were compared between propensity score-matched cohorts of M-THA versus RA-THA and M-THA versus CA-THA to adjust for baseline characteristics and comorbidities. Results. RA-THA and CA-THA did not exhibit any clinically meaningful reduction in mean LOS (RA-THA 2.2 days (SD 1.4) vs 2.3 days (SD 1.8); p < 0.001, and CA-THA 2.5 days (SD 1.9) vs 2.7 days (SD 2.3); p < 0.001, respectively) compared to their respective propensity score-matched M-THA cohorts. RA-THA, but not CA-THA, had similar non-home discharge rates to M-THA (RA-THA 17.4% vs 18.5%; p = 0.205, and 18.7% vs 24.9%; p < 0.001, respectively). Implant-related mechanical complications were lower in RA-THA (RA-THA 0.5% vs M-THA 3.1%; p < 0.001, and CA-THA 1.2% vs M-THA 2.2%; p < 0.001), which was associated with a significantly lower in-hospital dislocation (RA-THA 0.1% vs M-THA 0.8%; p < 0.001). Both RA-THA and CA-THA demonstrated higher mean higher index in-hospital costs (RA-THA $18,416 (SD $8,048) vs M-THA $17,266 (SD $8,396); p < 0.001, and CA-THA $20,295 (SD $8,975) vs M-THA $18,624 (SD $9,226); p < 0.001, respectively). Projections indicate that 23.9% and 3.2% of all THAs conducted in 2025 will be robotic arm- and computer-assisted, respectively. Projections indicated that RA-THA use may overtake M-THA by 2028 (48.3%) and reach 65.8% of all THAs by 2030. Conclusion. Technology-assisted THA, particularly RA-THA, may provide value by lowering in-hospital early dislocation rates and and other in-hospital metrics compared to M-THA. Higher index-procedure and hospital costs warrant further comprehensive cost analyses to determine the true added value of RA-THA in the episode of care, particularly since we project that one in four THAs in 2025 and two in three THA by 2030 will use RA-THA technology. Cite this article: Bone Joint J 2021;103-B(9):1488–1496

Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health (DoH) in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA). Waiting list information was obtained via a Freedom of Information request to the DoH (May 2021) and National Joint Registry data was used to determine baseline operative numbers. Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to determine the time to clear the waiting lists for THA using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections. As of May 2021, there were 3,757 patients awaiting primary THA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum added to the waiting list for primary THA and there were a mean 1,624 primary THAs performed per annum. The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre COVID-19 pandemic capacity and will be achieved in 2030 if capacity is 170%. Surgical capacity must exceed pre-Covid capacity by at least 30% to meet ongoing demand. THA capacity was significantly reduced following resumption of elective orthopaedics post-COVID-19 (22% of pre-COVID-19 capacity – 355 THAs/annum post-COVID-19 versus 1,624/annum pre-COVID-19). This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip arthroplasty. Waiting times for THA surgery in the NHS in Northern Ireland are likely to remain greater than 52 weeks for most of this decade

Aims. The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). Methods. This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. Results. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). Conclusion. While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J 2021;103-B(3):500–506

Aims. A recent report from France suggested an association between the use of cobalt-chrome (CoCr) femoral heads in total hip arthroplasties (THAs) and an increased risk of dilated cardiomyopathy and heart failure. CoCr is a commonly used material in orthopaedic implants. If the reported association is causal, the consequences would be significant given the millions of joint arthroplasties and other orthopaedic procedures in which CoCr is used annually. We examined whether CoCr-containing THAs were associated with an increased risk of all-cause mortality, heart outcomes, cancer, and neurodegenerative disorders in a large national database. Methods. Data from the National Joint Registry was linked to NHS English hospital inpatient episodes for 374,359 primary THAs with up to 14.5 years' follow-up. We excluded any patients with bilateral THAs, knee arthroplasties, indications other than osteoarthritis, aged under 55 years, and diagnosis of one or more outcome of interest before THA. Implants were grouped as either containing CoCr or not containing CoCr. The association between implant construct and the risk of all-cause mortality and incident heart failure, cancer, and neurodegenerative disorders was examined. Results. There were 158,677 individuals (42.4%) with an implant containing CoCr. There were 47,963 deaths, 27,332 heart outcomes, 35,720 cancers, and 22,025 neurodegenerative disorders. There was no evidence of an association between patients with CoCr implants and higher rates of any of the outcomes. Conclusion. CoCr-containing THAs did not have an increased risk of all-cause mortality, or clinically meaningful heart outcomes, cancer, or neurodegenerative disorders into the second decade post-implantation. Our findings will help reassure clinicians and the increasing number of patients receiving primary THA worldwide that the use of CoCr-containing implants is not associated with significant adverse systemic effects. Cite this article: Bone Joint J 2022;104-B(3):359–367

Use of large databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and vary in methodology of data acquisition. The purpose of this study was to evaluate differences in reported demographics, comorbidities and complications following total hip arthroplasty (THA) amongst four commonly used databases. Patients who underwent primary THA during 2010–2012 were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED) and Humana Claims Database (HAC). NSQIP definitions for comorbidities and surgical complications were queried in NIS, MED, and HAC using coding algorithms. Age, sex, comorbidities, inpatient and 30-day postoperative complications were compared (NIS has inpatient data only). Primary THAs from each database were 22,644 (HAC), 371,715 (MED), 188,779 (NIS) and 27,818 (NSQIP). Age and gender distribution were similar between databases. There was variability in the prevalence of comorbidities and complications depending upon the database and duration of post-operative follow-up. HAC and MED had twice the prevalence of COPD, coagulopathy and diabetes than NSQIP. NSQIP had more than twice the obesity than NIS. HAC had more than twice the rates of 30-day complications at all endpoints compared to NSQIP and more than twice the DVTs, strokes and deep infection as MED at 30-days post-op. Comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of infections and DVTs are captured when analysis is extended from inpatient stay to 30-days post-op. Amongst databases commonly used in orthopaedic research, there is considerable variation in complication rates following THA depending upon the database. It will be important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models