Introduction. Orthopaedic theatres can be noisy. Noise exposure is known to be related to reduced cognition, reduced manual dexterity and increased rates of post-operative wound infection. Up to 50% of orthopaedic theatre staff have features of Noise-Induced Hearing Loss (NIHL) with higher levels in consultants compared to registrars. Exposure to noise levels of 90dB(A) at work for a career of 40 years, equates to a 51% risk of hearing loss. Materials & methods. A Casella CEL-242 meter was positioned in the corner of the theatre tent. Recordings were taken for 17 Total Knee Replacements (TKRs) and 11 Total Hip Replacements (THRs). This meter recorded the decibel level once per second (whereas EU Regulation requires equivalent continuous level measurement). Results. Noise levels reached 105.6dB(A) using a hammer during a TKR and 97.9dB(A) with an oscillating saw. Decibel levels exceeded 90dB(A) in every operation within the sample. Percentages of readings at 80.0dB(A) or above, per case, were calculated to estimate the proportion of our data above the EU regulation Lower Action Level; the maximum was 12.6% and they appeared to be greater in TKRs. Discussion. The small percentage of values at 80.0dB(A) or above indicates that the equivalent continuous decibel level for an average 8 hour day would be below the EU Lower Action Level. It was expected that TKRs would have higher percentages of decibels at 80.0dB(A) or above, given the greater time spent sawing in this procedure. Exposure to levels above 90dB (which occurred in every case) for short time periods is proven to cause irreversible loss of hearing. Minor damage accumulates throughout a career of 40 years, and can result in NIHL. Conclusion. Tools used in orthopaedic theatre produce impulse noises that can cause NIHL. Average daily exposure can be assumed to be acceptable. Further investigation is required

The purpose of this randomized controlled trial is to evaluate the efficacy of using dilute betadine versus sterile saline lavage in aseptic revision total knee (TKA) and hip (THA) arthroplasty to prevent acute postoperative deep periprosthetic joint infection (PJI). Of the 450 patients that were randomized, 5 did not have 90-day follow-up, 9 did not receive the correct treatment, and 4 were excluded for intraoperative findings consistent with PJI. 221 Patients (144 knees and 77 hips) received saline lavage only and 211 (136 knees and 75 hips) received a three-minute dilute betadine lavage (0.35%) prior to wound closure. Patients were observed for the incidence of acute postoperative deep PJI within 90 days of surgery. Statistical analysis was performed using t-tests or Fisher's exact test where appropriate. Power analysis determined that 285 patients per group are needed to detect a reduction in the rate of PJI from 5% to 1% (alpha=0.05, beta=0.20). There were seven PJIs in the saline group and one in the betadine lavage group (3.2% vs. 0.5%, p=0.068). There were no significant differences in any baseline demographics between groups suggesting appropriate randomization. Although we believe the observed difference between treatments is clinically relevant, it was not statistically significant with the sample size enrolled thus far and enrollment is ongoing. Nonetheless, we believe that these data suggests that dilute betadine lavage is a simple method to reduce the rate of acute postoperative PJI in patients undergoing aseptic revision procedures

Aims

The aim of this study was to determine if the Oxford Knee and Hip Score (OKHS) can accurately predict when a primary knee or hip referral is deemed nonsurgical versus surgical by the surgeon during their first consultation, and to identify nonsurgical OKHS screening thresholds.

Background

Delay in access to primary total hip (THA) arthroplasty continues to pose a substantial burden to patients and society in publicly funded healthcare systems. The majority of strategies to decrease wait times have focused on the time from surgical consult to surgery, however a large proportion of total wait time for these patients is the time from primary care referral to surgical consultation. Prioritization scoring tools and patient reported outcome measures are being used in an attempt to ration limited resources in the face of increasing demand. However, to our knowledge, no study has investigated whether a referral Oxford Hip Score (OHS) could be used to triage non-surgical referrals appropriately, in an effort to increase timely access to specialists for patients that are candidates for total joint replacement (TJR).

Aims

The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen.

The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach. The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus. In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection). Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA

Aims. Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers. Methods. All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit. Results. Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed. Conclusion. Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85–89

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

Total joint arthroplasty (TJA) is a high value elective orthopaedic procedure, the indications for which may vary among surgeons as well as patients. The utilization of other discretionary procedures is known to be influenced by the availability of qualified surgeons. We investigated the existence of a correlation between geographic variation in TJA utilization and the regional density of arthroplasty surgeons. The number of Medicare-funded total hip (THA) and total knee (TKA) arthroplasties performed in predetermined geographic referral regions were obtained from the Dartmouth Atlas for 2012. The number of surgeons specializing in total joint arthroplasty in each respective region was derived from the AAHKS membership list. Linear regression was used to assess the relationship between number of arthroplasties performed per 1000 Medicare beneficiaries and the number of AAHKS-members per 100,000 beneficiaries in each Hospital Referral Region (HRR). For THA in aggregate, a positive correlation was found between number of THA performed per 1,000 beneficiaries and increasing TJA surgeon density. Positive correlations were also noted when HRRs were stratified by size from 50,000 to 250,000 beneficiaries. The number of THA performed per 1,000 beneficiaries in regions with AAHKS members was greater than in regions without (4.03 vs 3.29; p=0.008). In contrast, there was no correlation between the rate of TKA utilization and HRR surgeon density, and no consistent relationship between TKA rate and HRRs stratified by size. Likewise, there was no difference in the rate of TKA between HRRs with and without AAHKS members (8.48 vs 8.84; p=0.18). The frequency of THA positively correlates with AAHKS surgeon density in all but the largest HRRs and was greater in regions with AAHKS members than in those without. Such relationships were not apparent for TKA utilization. These data may have important implications for more cost-effective utilization of THA

Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

Objectives

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

Aims

The primary aim of this independent prospective randomised trial was to compare serum metal ion levels for ceramic-on-metal (CoM) and metal-on-metal (MoM) bearing surfaces in total hip arthroplasty (THA). Our one-year results demonstrated elevation in metal ion levels above baseline with no significant difference between the CoM and MoM groups. This paper reviews the five-year data.

Aims

This paper describes the methodology, validation and reliability of a new computer-assisted method which uses models of the patient’s bones and the components to measure their migration and polyethylene wear from radiographs after total hip arthroplasty (THA).

Aims

Femoral stems with exchangeable (modular) necks were introduced to offer surgeons an increased choice when determining the version, offset and length of the femoral neck during total hip arthroplasty (THA). It was hoped that this would improve outcomes and reduce complications, particularly dislocation. In 2010, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) first reported an increased rate of revision after primary THA using femoral stems with an exchangeable neck. The aim of this study was to provide a more comprehensive up-to-date analysis of primary THA using femoral stems with exchangeable and fixed necks.

The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States.

Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines.

Cite this article: Bone Joint J 2017;99-B(4 Supple B):3–10.

Aims

We compared the outcome of total hip arthroplasty (THA) in obese patients who previously underwent bariatric surgery and those who did not, in a matched cohort study.

Aims

The primary aim of this study was to analyse the position of the acetabular and femoral components in total hip arthroplasty undertaken using an anterior surgical approach.

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure.

A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment.

The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (sd) 0.9) vs 1.5 L (sd 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group.

The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE.

Cite this article: Bone Joint J 2015;97-B:1604–7.

This conversation represents an attempt by several arthroplasty surgeons to critique several abstracts presented over the last year as well as to use them as a jumping off point for trying to figure out where they fit in into our current understanding of multiple issues in modern hip and knee arthroplasty.

Total hip replacement causes a short-term increase in the risk of mortality. It is important to quantify this and to identify modifiable risk factors so that the risk of post-operative mortality can be minimised. We performed a systematic review and critical evaluation of the current literature on the topic. We identified 32 studies published over the last 10 years which provide either 30-day or 90-day mortality data. We estimate the pooled incidence of mortality during the first 30 and 90 days following hip replacement to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81), respectively. We found strong evidence of a temporal trend towards reducing mortality rates despite increasingly co-morbid patients. The risk factors for early mortality most commonly identified are increasing age, male gender and co-morbid conditions, particularly cardiovascular disease. Cardiovascular complications appear to have overtaken fatal pulmonary emboli as the leading cause of death after hip replacement.

Cite this article: Bone Joint Res 2014;3:175–82