Arthroplasties are widely performed to improve mobility and quality of life for symptomatic knee/hip osteoarthritis patients. With increasing rates of Total Joint Replacements in the United Kingdom, predicting length of stay is vital for hospitals to control costs, manage resources, and prevent postoperative complications. A longer Length of stay has been shown to negatively affect the quality of care, outcomes and patient satisfaction. Thus, predicting LOS enables us to make full use of medical resources. Clinical characteristics were retrospectively collected from 1,303 patients who received TKA and THR. A total of 21 variables were included, to develop predictive models for LOS by multiple machine learning (ML) algorithms, including Random Forest Classifier (RFC), K-Nearest Neighbour (KNN), Extreme Gradient Boost (XgBoost), and Na¯ve Bayes (NB). These models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance. A feature selection approach was used to identify optimal predictive factors. Based on the ROC of Training result, XgBoost algorithm was selected to be applied to the Test set. The areas under the ROC curve (AUCs) of the 4 models ranged from 0.730 to 0.966, where higher AUC values generally indicate better predictive performance. All the ML-based models performed better than conventional statistical methods in ROC curves. The XgBoost algorithm with 21 variables was identified as the best predictive model. The feature selection indicated the top six predictors: Age, Operation Duration, Primary Procedure, BMI, creatinine and Month of Surgery. By analysing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA and THR, and the XgBoost algorithm performed the best, in terms of accuracy of predictive performance. As this model was originally crafted at Ashford and St. Peters Hospital, we have naturally named it as THE ASHFORD OUTCOME

Aims. While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. Methods. In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. Results. A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). Conclusion. The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3–8

In-hospital length of stay (LOS) and discharge disposition following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, we wished to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge disposition following robotic-arm assisted (RO THA) versus conventional technique Total Hip Arthroplasty (CO THA). This large-scale, single institution study included patients of any age undergoing primary THA (N = 1,732) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for Post Anaesthesia Care Unit (PACU) admission, anaesthesia type, readmission within 30 days and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. The median LOS in the RO THA group was 54 hours (34, 78) versus 60 (51, 100) in the CO THA group, p<0.001. Discharge disposition was comparable between the two groups. In the multivariate model, age, need for PACU admission, ASA score > 2, female gender, general anaesthesia and utilisation of the conventional technique were significantly associated with LOS > 2 days. Our study showed that robotic-arm assistance was associated with a shorter LOS in patients undergoing primary THA and no difference in discharge destination. Our results suggest that robotic-arm assistance could be advantageous in partly addressing the upsurge of hip arthroplasty procedures and the concomitant health care burden; however, this needs to be corroborated by long-term cost effectiveness analyses and data from randomised controlled studies

The burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015), chronic obstructive pulmonary disease (p=0.016), renal disease (p=0.009), and mental illness (p=0.03). Increased body mass index (BMI) was not associated with a significant increase in LOS (r=0.01, p=0.83). Increased readmission rates were associated with comorbidities including hypertension (p=<0.0001), coronary artery disease (p=<0.0001), congestive heart failure (p=0.0007), peripheral vascular disease (p=<0.0001), chronic obstructive pulmonary disease (p=0.003), asthma (p=0.0128), renal disease (p=0.0001), and mental illness (p=0.0147). Obesity was not associated with increased readmission rates until the patients were morbidly obese (>40 BMI; p=0.03). Although the LOS decreased over the time of the study, this did not result in an adverse increase in readmission rates. Several comorbidities including hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and mental illness were all associated with both a longer LOS and an increase in readmission rates. Asthma was associated with increased readmission rates only and diabetes was associated with an increased LOS only. BMI was not associated with readmission rates unless the BMI exceeded 40 and had no significant effect on LOS at any BMI level

Introduction. With the removal of total hip arthroplasty (THA) from the Centers for Medicare & Medicaid Services (CMS) inpatient-only list, understanding predictors of length of stay (LOS) after THA is critical. Thus, we aimed to determine the influence of patient- and procedure-related risk factors as predictors of >1-day LOS after THA. Methods. A prospective cohort of 5,281 patients underwent primary THA between January 2016 and April 2019. Risk factors increased LOS were categorized as patient-related (demographics, smoking status, baseline Veterans RAND 12 Item Health Survey Mental Component Summary score [VR-12 MCS], Charlson Comorbidity Index [CCI], surgical indication, baseline Hip Injury and Osteoarthritis Outcome Score [HOOS] pain subscore and baseline HOOS physical function shortform (HOOS-PS), range of motion, and predicted discharge disposition) or procedure-related (hospital site, surgeon, approach, day of surgery, and surgery start time). By using the Akaike information criterion (AIC) and internally-validated concordance probabilities (C-index) for discriminating a 1-day LOS from a >1-day LOS, we compared performance between a patient-related risk factors only model and a model containing both patient- and procedure-related risk factors. Results. A >1-day LOS was statistically significantly associated with older age (p<0.001), female sex (p<0.001), higher body mass index (BMI) (p<0.001), higher CCI (p<0.001), Medicare status (p=0.012), higher baseline HOOS-PS (P<0.001) and lower baseline VR-12 MCS scores (p<0.001). The C-index after 1,000 bootstrap iterations were 0.693 and 0.883 for patient-related and patient plus procedure-related factors, respectively. Upon addition of procedure-related risk factors to the model, the AIC decreased by approximately 1,100 units, indicating that procedure-related risk factors (especially hospital site and surgical approach) explain LOS more effectively than patient-related risk factors alone. Conclusions. Although patient-related risk factors provide substantial predictive value for LOS following THA, procedure-related risk factors (mainly hospital site and surgical approach) remain the main drivers of predicting LOS. These results can help clinicians select appropriate candidates for short-stay and outpatient THA

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

Introduction. In rheumatoid (RA) patients undergoing total joint arthroplasty, evidence suggests methotrexate should be continued without increase in post-operative infection. Prednisolone increases post-operative infection risk, but cannot be stopped without risk of Addisonian events. Insufficient evidence exists to clarify perioperative biologic agent management. We currently stop biologics 2 weeks prior to operation and reintroduced following wound healing. Patients/Materials & Methods. This service evaluation reviewed infection rates and length of stay in RA patients following lower-limb arthroplasty, on various anti-rheumatoid therapies across a 28-month period. Results. Forty cases were identified: 15% on no anti-rheumatoid treatment, 45% on mono-therapy (8 on methotrexate, 8 on prednisolone, 2 on biologics)) and 40% on combination-therapy. The total population post-operative infection rate was 18% (all superficial wound). Mean length of stay was 8.0 days (SD=6.8). Methotrexate takers had an infection rate of 5% versus 33% in non-methotrexate takers (p=0.017), and a length of stay of 6.5 days versus 9.9 days in non-MTX takers (p=0.005). Prednisolone takers had an infection rate of 37% versus 0% in non-prednisolone takers (p=0.002) and length of stay was 12.0 days versus 4.7 days in non-prednisolone takers days (p=0.006). Biologics takers had similar infection rates of 9% versus 21% in non-biologic takers (p>0.05), and a similar length of stay of 6.6 days versus 8.6 days in non-biologic takers (p>0.05). Discussion. This data supports current evidence that methotrexate should be continued without detriment to infection risk and length of stay. Biologic agents stopped 2 weeks prior to operation appear to have no effect on infection rate and length of stay. Patients on prednisolone should be identified as at a higher risk of infection and should plan for a longer length of stay. Conclusion. Larger scale cohort studies are required to determine whether biologic agents should be continued per-operatively

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications. Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications. Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

Introduction. Hip and knee replacements are predictable orthopaedic procedure with excellent clinical outcomes. Discharging or leaking wounds affect length of hospital stay, affect bed planning and predispose to superficial and potentially deep wound infection. Predictable wound healing therefore remains the first hurdle. This trial aims to study the effectiveness of portable disposable incisional negative pressure wound therapy (NPWT) dressings in hip and knee replacements. This trial aims to study the effectiveness of portable disposable incisional negative pressure wound dressings in hip and knee replacements and the impact on wound healing, length of stay and wound complications. Patients/Materials & Methods. Following ethical approval 110 patients each were randomised to ‘Control group’ and ‘Study group’. Patients in control group received traditional dressings and those in study group received an incisional NPWT (PICO) manufactured by Smith & Nephew. Post operatively, state of the wound, level of wound exudate, length of hospital stay and complications were documented. Results. The average length of stay for control group was 4.72 ± 0.69 (Mean ± SEM) and for the study group 3.79±0.19 (mean ± SEM. Eight percent of the control group patients had wound related complications as opposed to 2% complications in the study group. The mechanical and device related issues in the study group accounted to 10%. Discussion. There is little evidence as to whether wound dressing choices affect wound healing in incisional wounds. There is good evidence for negative pressure wound therapy (NPWT) in complex, open and chronic wounds; however the concept of application of NPWT to routine incisional wounds is novel. Advances such as disposable and portable negative devices have made this option attractive in elective surgery. Conclusion. Our study shows that its application in routine primary hip and knee replacement can improve wound healing, facilitate early and predictable discharge from the hospital and reduce post discharge complications. This is particularly true for high risk wounds such as patients with BMI of >35 and is cost effective

The ‘Best Practice Tariff‘ (BPT) was developed to improve hip fracture care by incentivising hospitals to provide timely multidisciplinary care to patients sustaining these injuries. The current literature examining the association between BPT and patient outcomes is conflicting and underpowered. We aimed to determine if achieving BPT has an impact on 30-day mortality and postoperative length of stay. A retrospective analysis for patients admitted to a major trauma centre (MTC) was performed between 01/01/2013 to 31/12/2020. Data were extracted from the National Hip Fracture Database. The study population was divided into two groups: those who achieved all BPT criteria (BPT-passed) and those who did not (BPT-failed). The primary outcomes of interest included the 30-day mortality rate and postoperative length of stay (LOS). As a secondary objective, we aimed to assess factors that predict perioperative mortality by utilising a logistic regression model. 4397 cases were included for analysis. 3422 (78%) met the BPT criteria, whereas 973 (22%) did not. The mean LOS in the BPT-achieving group was 17.2 days compared with 18.6 in the BPT-failed group, p<0.001. 30-day mortality was significantly lower in the BPT-achieving group i.e., 4.3% in BPT-achieved vs. 12.1% in BPT-failed, p<0.001. Logistic regression modelling demonstrated that attainment of BPT was associated with significantly lower 30-day mortality (OR: 0.32; 95% CI:0.24–0.41; p<0.001). To our knowledge, this is the largest study to investigate the association between BPT attainment and 30-day mortality as well as the length of stay. The present study demonstrates that achieving BPT in hip fracture patients is associated with a significant reduction in the average length of stay and 30-day mortality rates. Our crude calculations revealed that achieving BPT for 3422 patients earned our hospital trust >£4 million over 8 years. Findings from this study suggest that achieving BPT not only improves 30-day survival in patients with hip fractures but also aids cost-effectiveness by reducing LOS and helps generate NHS Trusts a significant amount of financial reward

We analysed which pre-operative factors could be used to predict the length of in-patient stay following unilateral primary total hip replacement undertaken for osteoarthritis. Data were collected prospectively from 2302 patients undergoing primary total hip replacement over a nine-year period. The relationships between the various pre-operative factors and length of stay were studied separately using either Student’s t-test or Pearson’s correlation, and then subjected to multiple linear regression analysis. The mean length of stay was 8.1 days (median 7; 3 to 58). After adjusting for the effects of other pre-operative factors, younger age, male gender, higher combined Harris hip function and activity score, higher general health perception dimension of the Short-Form 36 score, and non-steroidal anti-inflammatory drug use were all found to be significantly associated with a reduced length of stay

Introduction. Total Hip Replacement (THR) is an effective treatment for end stage degenerative disease of the hip and offers patients the prospect of long term pain relief, improved joint function and quality of life. Enhanced Recovery Programmes (ERP) aim to standardise routine perioperative care, reduce hospital length of stay (LOS) and promote rapid recovery after elective surgery. The aim of this study was to determine whether the implementation of an ERP could successfully reduce the length of hospital stay associated with primary THR and whether this could be achieved without compromising the expected functional outcome or risking an increased dislocation rate. Patients/Materials & Methods. Prospectively collected data on 1161 patients (611 managed with traditional rehabilitation and 550 with ERP) undergoing primary unilateral THR between 2005 and 2013 was retrospectively reviewed. Univariable statistical analysis was undertaken to identify factors that appeared to predict length of stay and a multiple linear regression model was then constructed to determine the significance and strength of effect of the individual predictors. Results. Median LOS was 5 days for those managed in the traditional method and 3 days for those managed with ERP (p<0.001). Multivariate regression models demonstrate that this effect on LOS is independent of and stronger than other factors affecting LOS and we did not observe increased rates of dislocation (1.03% versus 0.73%, p=0.75) or mortality (1.5% versus 0.6%, p=0.14) at one year postoperative in patients managed with ERP. Both groups demonstrated significant improvement in mean Harris Hip Score (+42.8 versus +41.5) at twelve to eighteen months postoperative and there was no significant difference in the magnitude of improvement between groups (p=0.09). Discussion. This is the first study to demonstrate the independent effect of ERP on LOS through multiple regression analysis and to directly compare functional outcomes of patients managed with ERP with the accepted gold standard (traditional rehabilitation) and these findings will be of use to surgeons counselling patients peiroperatively and healthcare planners. Conclusion. Implementation of ERP can reduce the hospital LOS for primary THR without adverse effects on dislocation rates and functional outcomes at 12 to 18 months postoperative

Aims. The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. . Patients and Methods. Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. . Results. The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). . Conclusion . We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. Take home message: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality. Cite this article: Bone Joint J 2016;98-B:475–82

Aims. To examine incidence of complications associated with outpatient total hip arthroplasty (THA), and to see if medical comorbidities are associated with complications or extended length of stay. Patients and Methods. From June 2013 to December 2016, 1279 patients underwent 1472 outpatient THAs at our free-standing ambulatory surgery centre. Records were reviewed to determine frequency of pre-operative medical comorbidities and post-operative need for overnight stay and complications which arose. Results. In 87 procedures, the patient stayed overnight for 23-hour observation, with 39 for convenience reasons and 48 (3.3%) for medical observation, most frequently urinary retention (13), obstructive sleep apnoea (nine), emesis (four), hypoxia (four), and pain management (six). Five patients (0.3%) experienced major complications within 48 hours, including three transferred to an acute facility; there was one death. Overall complication rate requiring unplanned care was 2.2% (32/1472). One or more major comorbidities were present in 647 patients (44%), including previous coronary artery disease (CAD; 50), valvular disease (nine), arrhythmia (219), thromboembolism history (28), obstructive sleep apnoea (171), chronic obstructive pulmonary disease (COPD; 124), asthma (118), frequent urination or benign prostatic hypertrophy (BPH; 217), or mild chronic renal insufficiency (11). Conclusion. The presence of these comorbidities was not associated with medical or surgical complications. However, presence of one or more major comorbidity was associated with an increased risk of overnight observation. Specific comorbidities associated with increased risk were CAD, COPD, and frequent urination/BPH. Outpatient THA is safe for a large proportion of patients without the need for a standardised risk assessment score. Risk of complications is not associated with presence of medical comorbidities. Cite this article: Bone Joint J 2018;100-B(1 Supple A):31–5

Introduction

Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI.

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions.

In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Cite this article: Bone Joint J 2013;95-B:1587–94.

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

Patients undergoing total hip or knee arthroplasty (THA/TKA) are commonly associated with high pain scores and narcotic use. Duloxetine is effective in relieving chronic pain. The aim of this study was to evaluate the safety and efficacy of duloxetine for pain management following THA/TKA. Five major databases (PubMed, Embase, Scopus, Cochrane, and Web of Science) were searched for randomised controlled trials (RCTs) that compared duloxetine to placebo in patients that underwent THA/TKA. The primary outcome was pain reduction with rest and movement at short-term and long-term time intervals. Secondary outcomes were the use of analgesics, length of stay, and safety profile. The risk of bias was assessed using the Cochrane tool. Data were pooled using RevMan 5.4. The results were reported as mean difference (MD) or standardised MD (SMD) and 95% confidence intervals (CI). Eight RCTs with 767 patients were included. 50.2% (n=385/767) of patients received duloxetine. After one day, duloxetine was superior to the control regarding pain reduction with rest (SMD= −0.22 [−0.41, −0.03], p=0.02) after sensitivity analysis and pain reduction at movement (SMD= −0.39 [−0.55, −0.24], p<0.001). Similarly, after 12 weeks, duloxetine significantly reduced pain with rest (SMD= −0.3 [−0.52, −0.09], p=0.006) and pain with movement (SMD= −0.52 [−0.87, −0.17], p=0.003). In addition, after sensitivity analysis, duloxetine was associated with less analgesic use after one day (MD= −4.65 [−7.3, −2.01], p<0.001) and two days (MD= −5.65 [−10.62, −0.67], p=0.03). Patients who received duloxetine also required fewer analgesics after three days. However, there was no significant difference between the duloxetine and control groups in analgesic use after one week, length of stay, and adverse events. Duloxetine was superior to the placebo regarding short-term and long-term pain reduction with rest and movement following THA/TKA. Duloxetine reduced postoperative analgesic use. There was no significant difference between duloxetine and placebo regarding adverse events and length of stay