Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition. 603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³. Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European. This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation

In this study we compare survivorship and patient reported outcome measures in robotically assisted versus conventional Total Hip Arthroplasty (THA).

This paper investigates the hypothesis that implant survival and PROMS following THAs performed with robotic assistance were not different to outcomes following conventional THAs.

Data included all patients undergoing THA for osteoarthritis between 19 April 2016 and 31 December 2020. Analysis of PROMS outcomes was restricted to those who had completed PROMS data preoperatively and at 6 months postoperatively.

There were 157,647 procedures, including 3567 robotically assisted procedures, available for comparison of revision rates. 4557 procedures, including 130 robotically assisted procedures, had PROMS data available. The revision rate of primary THA performed with robotic assistance was not statistically different from THA performed by conventional methods (4 year cumulative percent revision 3.1% v 2.7%; HR = 1.05, p=0.67). The Oxford Hip Score, VAS for pain and the EQ-VAS score for overall health showed no statistically significant difference between the groups. The EQ-5D Utility Score showed an improved score (median score 1 v 0.88; OR = 1.58, p=0.007) for the robotically assisted group compared to the conventional group.

Robotic assisted THA was not associated with significant improvement in early revision or joint-specific PROMs. The findings may have been biased, in either direction, by unmeasured patient, surgeon, hospital and prosthesis factors. The findings (including the difference in health-related quality of life) may have also been influenced by lack of blinding. Future research should include methods to minimise these biases.

Immigrated Canadians make up approximately 20% of the total population in Canada, and 30% of the population in Ontario. Despite universal health coverage and an equal prevalence of severe arthritis in immigrants relative to non-immigrants, the former may be underrepresented amongst arthroplasty recipients secondary to challenges navigating the healthcare system. The primary aim of this study was to determine if utilization of arthroplasty differs between immigrant populations and persons born in Canada. The secondary aim was to determine differences in outcomes following total hip and knee arthroplasty (THA and TKA, respectively). This is a retrospective population-based cohort study using health administrative databases. All patients aged ≥18 in Ontario who underwent their first primary elective THA or TKA between 2002 and 2016 were identified. Immigration status for each patient was identified via linkage to the ‘Immigration, Refugee and Citizenship Canada’ database. Outcomes included all-cause and septic revision surgery within 12-months, dislocation (for THA) and total post-operative case cost and were compared between groups. Cochrane-Armitage Test for Trend was utilized to determine if the uptake of arthroplasty by immigrants changed over time. There was a total of 186,528 TKA recipients and 116,472 THA recipients identified over the study period. Of these, 10,193 (5.5%) and 3,165 (2.7%) were immigrants, respectively. The largest proportion of immigrants were from the Asia and Pacific region for those undergoing TKA (54.0%) and Europe for THA recipients (53.4%). There was no difference in the rate of all-cause revision or septic revision at 12 months between groups undergoing TKA (p=0.864, p=0.585) or THA (p=0.527, p=0.397), respectively. There was also no difference in the rate of dislocations between immigrants and people born in Canada (p=0.765, respectively). Despite having similar complication rates and costs, immigrants represent a significantly smaller proportion of joint replacement recipients than they represent in the general population in Ontario. These results suggest significant underutilization of surgical management for arthritis among Canada's immigrant populations. Initiatives to improve access to total joint arthroplasty are warranted

Aim. Our aim was to evaluate the prevalence and impact of unexpected intraoperative cultures on the outcome of total presumed aseptic knee and hip revision surgery. Method. Data regarding patients prospectively recruited in our center, who had undergone elective complete hip and knee revision surgery from January 2003 to July 2017 with a preoperative diagnosis of aseptic loosening was retrospectively reviewed. Partial revisions and patients with follow up below 60 months were excluded from the study. The protocol of revision included at least 3 intraoperative cultures. Failure was defined as the need for re-revision due to any-cause at 5 years and/or the need for antibiotic suppressive therapy. Results. A total of 608 cases were initially included in the study, 53 patients were excluded. 123 hip and 432 knee revision surgeries were included. 420 cases (75.7%) had all cultures negative, 114 (20.5%) a single positive culture or two of different microorganisms and 21 (3.8%) had at least 2 positive cultures for the same microorganism. Early failure was found in 4.8% (1/21) of the patients with missed low grade infection. The presence of positive cultures during total exchange was not associated with a higher failure rate than in those with negative cultures (44 of 420, 10.5%). In contrast, patients revised before 24 months had a significant higher rate of re-revision, 18% (15/83) vs. 8.4%. Conclusions. Total hip and knee revisions with unexpected positive cultures were not significantly associated with a higher re-revision risk at 5 years of follow-up. Representing an overall good prognosis. However, revision surgeries performed within the first 24 months have a higher rate of failure

The New Zealand Joint Registry (NZJR) was established in 1999. However, ethnicity data was not recorded by prioritisation in line with Ministry of Health (MoH) recommendations. Recently, cross-referencing with MoH updated ethnicity data for all 326,150 entries in the NZJR database. The objective of this national level, population study was to identify any ethnic disparities in access and outcome for Māori for primary total hip (THA) and knee arthroplasty (TKA) for Osteoarthritis. The utilisation rate for THA and TKAs were calculated for the Māori and NZ European population from all data in the NZJR and Census data in 2001, 2006, 2013 and 2018. Utilisation rate was reported separately for four age groups (<55, 55-64, 65-74, >75) over four time periods (1999-2004, 2005-2009, 2010-2014, 2015-2020). Revision rate, 6 months and 5-year Oxford scores were adjusted for age, sex and BMI, then compared between groups. In every age group and at all but one time point, significant under-utilisation of TKA was observed in Māori. For THAs, Māori had similar utilisation rates in the <55 and 55-64 age groups, but significantly lower utilisation rates in all other age groups. When adjusted for age, sex and BMI, no significant differences in revision rates were observed between Māori and NZ Europeans for THAs (HR 0.939, P 0.417) or TKAs (HR 1.129, P 0.149). Adjusted 6 months and 5-year Oxford scores were significantly higher in NZ Europeans, however, the maximum difference was less than 3 points and is unlikely to be clinically significant. Despite the same risk of being diagnosed with osteoarthritis, Māori are less likely to undergo THA and TKA. There are no clinically significant differences in outcomes post arthroplasty between Māori and NZ Europeans. Further research is required to investigate causes for lower utilisation in Māori

Aim. Periprosthetic joint infection (PJI) is one of the most serious and frequent complications in prosthetic surgery. Despite significant improvements in the criteria for diagnosis of PJI, the diagnostic workflow remains complex and, sometimes, inconclusive. Host immune factors hold great potential as diagnostic biomarkers in bone and joint infections. We have recently reported that the synovial concentration of the humoral pattern recognition molecule long pentraxin 3 (PTX3) is a sensitive and specific marker of PJI in total hip and knee arthroplasty patients (THA and TKA) undergoing revision surgery [1]. However, the contribution to risk and diagnosis of PJI of the genetic variation in PTX3 and inflammatory genes that are known to affect its expression (IL-1b, IL-6, IL-10, and IL-17A) has not been addressed. Therefore, we assessed these relationships in a cohort of THA and TKA patients who underwent prosthesis revision by focusing on a panel of single nucleotide polymorphisms (SNPs) in the PTX3, IL-1β, IL-6, IL-10 and IL-17A genes. Method. A case-control retrospective study was conducted on an historic cohort of patients that received THA or TKA revision and were diagnosed with PJI (cases) or aseptic complications (controls) [1]. Samples of saliva were collected from 93 subjects and used for extraction of genomic DNA to perform genotyping of the PTX3, IL-1β, IL-6, IL-10 and IL-17A polymorphisms. Moreover, whenever available, samples of synovial fluid and plasma [1] were used to measure the concentration of the IL-1β, IL-10, and IL-6 proteins by immunoassay. Uni-and multivariate analyses were performed to evaluate the relationships between genetic, biochemical, and clinical variables. Results. The rs3024491 (IL-10) and rs2853550 (IL-1b) SNPs were found to be strongly associated with the risk of PJI. The synovial levels of PTX3, IL-1β, IL-10, and IL-6 were higher in cases than in controls, and a clear correlation emerged between the synovial concentration of PTX3 and IL-1b in cases only. Also, we identified a causal relationship between rs2853550, synovial concentration of IL-1b and that of PTX3 (that is induced by IL-1b). Conclusions. Our findings suggest that SNPs in the IL-10 and IL-1b genes could be used for early identification of THA and TKA patients with high risk of PJI. It is therefore conceivable that integrating genetic data into current diagnostic criteria would improve diagnosis of PJI

Aim. It is unclear if the prevalence of resistance organisms causing (PJI) in total hip/knee arthroplasty is different among North/South American and European countries. Therefore, we sought to compare causative organisms, rates of resistant organisms, and polymicrobial infections in hospitals in North/South America, and Europe. Method. We performed a retrospective study of 654 periprosthetic hip (n=361) and knee (n=293) infections (January 2006-October 2019) identified at two facilities in the United States (US) (n=159), and single institutions located in Argentina (n=99), Uruguay (n=130), United Kingdom (UK) (n=103), Germany (n=59), and Russia (n=104). The analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05. Results. Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58%. In this regard, there was a significant difference between hips (62.3%) and knees (52.6%) (p=0.014). The rates of resistant organisms among countries were significantly different: 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (p<0.001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were: 9.4% in the US, 11.1% (Argentina), 4.6% (Uruguay), 4.9% (UK), 11.9% (Germany), and 16.3% (Russia) (p=0.026). In an exclusive analysis of the hips, the incidence of resistant organisms was 62.3% while polymicrobial infections accounted for 10.5% of all cultures. The rates of resistant organisms in each country were: 42.9% in the US, 59.2% (Argentina), 78.5% (Uruguay), 41.3% (UK), 63.9% (Germany), and 80.0% in Russia (p<0.001). The incidences of polymicrobial infections were: 9.1% in the US, 6.1% (Argentina), 6.5% (Uruguay), 6.5% (UK), 16.7% (Germany), and 21.7% in Russia (p=0.024). Regarding the knees, the incidence of resistant organisms was 52.6% while the frequency of polymicrobial infections was 7.8%. The rates of resistant organisms in each country were: 32.9% in the US, 74% (Argentina), 54.1% (Uruguay), 40.4% (UK), 60.9% (Germany), and 75% in Russia (p<0.001). The frequencies of polymicrobial infections were: 9.8% in the US, 16% (Argentina), 0% (Uruguay), 3.5% (UK), 4.3% (Germany), and 9.1% in Russia (p=0.072). Conclusions. Staphylococcus aureus and epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections. These differences between countries and continents may affect comparative studies that evaluate treatments for PJI

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared

Background. In surgeon controlled bundled payment and service models, the goal is to reduce cost but preserve quality. The surgeon not only takes on risk for the surgery, but all costs during 90 days after the procedure. If savings are achieved over a previous target price, the surgeon can receive a monetary bonus. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with cardiology consultation at their discretion, and without dictating specific testing. Our participation in the Bundled Payments for Care Improvement (BPCI) program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having costly readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 2,459 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 10/31/17 prior to instituting the new program. All had complete 90 day postoperative readmission data supplied by the CMS, with 25 (1%) of these patients having readmissions for cardiac events for a total cost of readmissions of %149,686. 14 of 25 had a preoperative clearance by a cardiologist. In 19 of the 25 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. Since instituting the new program, 842 additional surgeries were performed, 463 by the four surgeons involved. 126 patients were agreeable to be evaluated through the Preventive Cardio-Orthopaedics program. 4 patients of the four physicians still screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.33 days at a total cost of %42,321. 2 patients of the four physicians evaluated by the Preventive Cardio-Orthopaedics program had a cardiac related readmission, at an average hospital stay of 2 days, and at a total cost of %10,091. Conclusions. Risk sharing programs have forced surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high cardiac readmission risk. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

Venous thromboembolism (VTE) is a serious complication after total hip and knee arthroplasty. There is still no consensus regarding the best mode of thromboprophylaxis after lower limb arthroplasty. The aim of this study was to ascertain the efficacy, safety profile and rate of adverse thromboembolic events of aspirin as extended out of hospital pharmacological anticoagulation for elective primary total hip and knee arthroplasty patients and whether these rates were comparable with published data for low molecular weight heparin (LMWH). Data was extracted from a prospective hospital acquired thromboembolism (HAT) database. The period of study was from 1st Jan 2013-31st Dec 2016 and a total of 6078 patients were treated with aspirin as extended thromboprophylaxis after primary total hip and knee arthroplasty. The primary outcome measure of deep vein thrombosis and pulmonary embolism within 90 days postoperatively was 1.11%. The secondary outcome rates of wound infection, bleeding complications, readmission rate and mortality were comparable to published results after LMWH use. The results of this study clearly show that Aspirin, as part of a multimodal thromboprophylactic regime, is an effective and safe regime in preventing VTE with respect to risk of DVT or PE when compared to LMWH. It is a cheaper alternative to LMWH and has associated potential cost savings

Introduction. Total hip arthroplasty (THA) is a highly successful procedure achieving excellent clinical outcomes beyond 10 years post-surgery. With exception of periprosthetic infection, dislocation is the most common cause of failure in THA. A novel reverse total hip (RTH) replacement has been developed to address dislocation through reversal of the typical THA articulation in which a femoral cup and acetabular ball interlock at the extremes of motion to enhance mechanical stability in all planes. The purpose of this study was to assess the safety and efficacy of this novel RTH in a series of 22 patients and to monitor implant fixation using radiostereometric analysis (RSA). Methods. Twenty two patients with end-stage osteoarthritis of the hip were enrolled between 2017 and 2019 at a single center. All surgeries were performed by a group of four high-volume fellowship-trained arthroplasty surgeons. All patients received at least 1 acetabular cup screw and RSA markers inserted into the acetabulum and proximal femur. Follow-up time points were 6 weeks, 6, 12 and 24 months and included patient reported outcome measures (HOOS, Oxford-12, Harris Hip Score, SF-36 and Satisfaction) as well as RSA assessment. Results. The patient cohort consisted of 11 females and 11 males with mean age of 70.8 years and body mass index 31.3 kg/m. 2. At the time of writing, 21, 15 and 3 patients had completed their 6-month, 1- and 2-year clinical follow-ups, respectively. There was a significant improvement in function and pain with the RTH between pre-operative and six and twelve month follow up as collected by the HOOS, Oxfrod-12, HHS, WOMAC, EQ-5D and SF-36 PCS with p<0.001 for all. The sole exception was the SF-36 MCS which had a non-statistical improvement. Eighteen of 20 patients were satisfied or very satisfied with the outcome of surgery. Average vertical migration of the acetabular cup at 6 and 12 months was 0.082 mm and 0.110 mm, respectively. Average distal migration of the femoral stem at 6 and 12 months was 0.015 mm and 0.035 mm, respectively. Conclusions. Early results indicate acceptable safety and efficacy of this novel RTH for treating osteoarthritis of the hip. The femoral and acetabular components both appear well fixed at near-term follow-up, as assessed with RSA. Further follow-up will determine if these results are maintained at 24 months post-surgery. Additional patient enrollment will assess acetabular cup fixation without the use of screws. For any figures or tables, please contact authors directly

High complication rates and poor outcomes have been widely reported in patients undergoing revision of large head metal-on-metal arthroplasty. A previous study from our centre showed high rates of dislocation, nerve injury, early cup loosening and pseudotumor recurrence. After noting these issues, we implemented the following changes in surgical protocol in all large head MOM revisions: One: Use of highly porous shells in all cases. Two: Use of largest femoral head possible. Three: Low threshold for use of dual mobility and constrained liners when abductors affected or absent posterior capsule. Four: Use of ceramic head with titanium sleeve in all cases. Five: Partial resection of pseudotumor adjacent to sciatic and femoral nerves. The purpose of the present study is to compare the new surgical protocol above to our previously reported early complications in this group of patients. We specifically looked at (1) complications including reoperations, (2) radiologic outcomes, and (3) functional outcomes. Complication rates after (Group 1), and before (Group 2) modified surgical protocol were compared using Chi-square test, assuming statistical significance p < 0 .05. Major complications occurred in 4 (8.3%) of 48 patients who had modified surgical technique, compared to 12 (38%) of 32 revisions prior to modification (p < 0 .05). Two hips of 48 (4.17%) endured dislocations in Group 1, compared to 9 of 32 (28%) in Group 2 (p < 0 .05). Four patients of 48 had repeat revision in Group 1: 2 for recurrence of pseudotumor, 1 for dislocation, and 1 for infection, compared to 6 patients who had 7 repeat revisions of 32 patients in Group 2: 3 for acetabular loosening, 3 for dislocation, and 1 for recurrence of pseudotumor (p=0.1). None of 48 revisions in Group 1 had acetabular loosening, compared to 4 of 32 in Group 2 (p=0.02). Two patients had nerve injury in Group 2, compared to none in Group 1 (p=0.16). The mean WOMAC pain score was 87.1 of 100 and the function score was 88.4 of 100 in Group 1, compared to a mean WOMAC pain score of 78 of 100 (p=0.6) and a function score of 83 of 100 in Group 2 (p=0.8). Modification of the surgical techniques described in the introduction has resulted in a significant decrease in complications in revision of large head MOM total hips. We continue to use this protocol and recommend it for these difficult cases

This study aimed to evaluate the month-to-month prevalence of antibiotic dispensation in the 12 months before and after total knee arthroplasty (TKA) and total hip arthroplasty (THA) and to identify factors associated with antibiotic dispensation in the month immediately following the surgical procedure.

In total, 4,115 THAs and TKAs performed between April 2013 and June 2019 from a state-wide arthroplasty referral centre were analysed. A cross-sectional study used data from an institutional arthroplasty registry, which was linked probabilistically to administrative dispensing data from the Australian Pharmaceutical Benefits Scheme. Multivariable logistic regression was carried out to identify patient and surgical risk factors for oral antibiotic dispensation.

Oral antibiotics were dispensed in 18.3% of patients following primary TKA and 12.0% of patients following THA in the 30 days following discharge. During the year after discharge, 66.7% of TKA patients and 58.2% of THA patients were dispensed an antibiotic at some point. Patients with poor preoperative health status were more likely to have antibiotics dispensed in the month following THA or TKA. Older age, undergoing TKA rather than THA, obesity, inflammatory arthritis, and experiencing an in-hospital wound-related or other infectious complications were associated with increased antibiotic dispensation in the 30 days following discharge.

A high rate of antibiotic dispensation in the 30 days following THA and TKA has been observed. Although resource constraints may limit routine wound review for all patients by a surgeon, a select cohort may benefit from timely specialist review postoperatively. Several risk factors identified in this study may aid in identifying appropriate candidates for such changes to follow-up care.

Background. The Bundled Payments for Care Improvement (BPCI) was developed by the US Center for Medicare and Medicaid (CMS) to evaluate a payment and service delivery model to reduce cost but preserve quality. 90 day postoperative expenditures are reconciled against a target price, allowing for a monetary bonus to the provider if savings were achieved. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative cardiovascular readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with or without additional cardiology consultation, without dictating specific testing. Typical screening includes an EKG, occasionally an echocardiogram and nuclear stress test, and rarely a cardiac catheterization. Our participation in the BPCI program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having readmissions for cardiac events. Objective. To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion. Methods. The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission. Results. 1,361 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 1/28/18 and all had complete 90 day postoperative readmission data supplied by the CMS, with 25 of these patients evaluated through the Preventive Cardio- Orthopaedics program. 12 (0.90%) screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.67 days at a total cost of $69,378. 7 of 12 had a preoperative clearance by a cardiologist. In 9 of the 12 patients, the only preoperative cardiac screening tool performed was an electrocardiogram. None of these 25 patients evaluated through the new program has been readmitted. 84 more patients have been evaluated in this program since 1/28/18, but 90 day readmission data is still incomplete. Preliminary data suggests that the highest risk in these patients is not severe coronary artery disease, but atrial fibrillation, hypertension with left ventricular hypertrophy, and cardiac plaques with ulceration. Conclusions. Risk sharing programs have forced joint replacement surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high readmission risk with a cardiac event. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost

The pain of arthritic disorders occurs in a social and environmental context. Thus, the pain of arthritis not only can affect the patient, but also the spouse. Numerous investigations have shown that the spouses of individuals with persistent pain report lower levels of marital satisfaction, higher rates of depression and lower quality of life. For the vast majority of patients with osteoarthritis, total hip (THA) or total knee (TKA) arthroplasty results in a significant reduction in pain, emotional distress, disability and a significant improvement in their quality of life and function. Little is currently known about how these recovery-related changes impact on the spouse or the marital relationship. Patients and their spouses were recruited within one-year following the arthroplasty surgery. Couples participated in a semi-structured interview and were each asked to recall their level of pain on a numerical rating scale from 1 to 10 before and after recovering from surgery, and provide a numerical rating score (10 points) for a set of seven questions pertaining to their level of disability in seven different activities of daily living. In addition, the spouses were asked to list in order of importance the ways in which the surgery of their spouse affected their overall quality of life. In total, 33 couples (66 respondents) answered the survey questionnaire. There were 17 male patients, 16 female patients who underwent 29 THAs and 4 TKAs. With regard to pain, the spouses estimated their partner's pain, both preoperatively and at the time of the survey, to be at a significantly higher level than the patient's perception (p=0.05). The spouses perceived a greater improvement in family/home responsibilities, recreation and social activities, and in their occupation than that noted by the partner. After the arthroplasty, the spouses indicated that their lives had improved with respect to doing more activities/leisure (70%), because there partner had less suffering (61%), they had more independence/less caregiving (54%), it improved their marital relationship (54%), they had a better social/family life (27%) and they were able to travel (27%). In addition to the patient, THA and TKA result in a significant improvement in quality of life and marital functioning of the spouse. This should not continue to be unrecognized as a significant benefit of the procedure

Introduction. Recent advances in algorithms developed with passively collected sensor data from smart phones and watches demonstrate new, objective, metrics with the capacity to show qualitative gait characteristics. The purpose of this feasibility study was to assess the recovery of gait quality following primary total hip and knee arthroplasty collected using a smartphone-based care platform. Methods. A secondary data analysis of an IRB approved multicenter prospective trial evaluating the use of a smartphone-based care platform for primary total knee arthroplasty (TKA, n=88), unicondylar knee arthroplasty (UKA, n=28), and total hip arthroplasty (THA, n=82). Subjects were followed from 6 weeks preoperative to 24 weeks postoperative. The group was comprised of 117 females and 81 males with a mean age of 61.4 and BMI of 30.7. Signals were collected from the participants' smartphones. These signals were used to estimate gait quality according to walking speed, step length, and timing asymmetry. Post-operative measures were compared to preoperative baseline levels using a Signed-Rank test (p<0.05). Results. Mean walking speeds were lowest at postoperative week 2 for all three procedures (p<.001). The TKA population stabilized to preoperative speeds by week 17. For UKA cases, mean walking speeds rebounded to preoperative speed consistently by week 9 (p>.05). THA cases returned to preoperative walking speeds with a stable rebound starting at week 6 (p>.05), and improvement was seen at week 14 (p=.025). The average weekly step length was lowest in postoperative week 2 for both TKA and UKA (p<.001), and at week 3 for THA (p<.001). The TKA population rebounded to preoperative step lengths at week 9 (p=0.109), UKA cases at week 7 (p=.123), and THA cases by week 6 (p=.946). For TKA subjects, the change in average weekly gait asymmetry peaked at week 2 postoperatively (p <0.001), returning to baseline symmetry by week 13 (p=.161). For UKA cases, mean gait asymmetry also reached its maximum at week 2 (p =.006), returning to baseline beginning at week 7 (p=0.057). For THA cases mean asymmetry reached its maximum in week 2 (p <0.001) and was returned to baseline values at week 6 (p=.150). Discussion and Conclusion. Monitoring gait quality in real-world patient care following hip and knee arthroplasty using smart phone technology demonstrated recovery curves similar to previously reported curves captured by traditional gait analysis methods and patient reported outcome scores. Capturing such real-world gait quality metrics passively through the phone may also provide the advantage of removing the Hawthorne effect related to typical gait assessments and in-clinic observations, leading to a more accurate picture of patient function

Aim

There is limited data on the frequency and impact of untoward events such as glove perforation, contamination of the surgical field (drape perforation, laceration, detachment), the unsterile object in the surgical field (hair, sweat droplet…), defecation, elevated air temperature…that may happen in the operating theatre. These events should influence the surgical site infection rate but it is not clear to what extent. We wanted to calculate the frequency and measure the impact of these events on the infection and general revision rate.

OBJECTIVE. Debridement, Antibiotics and Implant Retention (DAIR) procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our perspective of DAIR in a relatively a small cohort following hip and knee replacements in a District General Hospital (DGH) in United Kingdom, where we delivered comparable results to leading tertiary centers in short to mid-term followup. METHODS. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Multiple samples were taken intraoperatively for cultures and histology. mMicrobiological support was provided by a microbiologist with interest in musculoskeletal infections. RESULTS. 14 patients [9 males, 5 females; age 62–78 years (Mean 70.7); BMI 22–44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms, (although the time from index surgery ranged from 15 days to 58 months). Patient selection was made by two Hip surgeons. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococcus. IV antibiotics were stated after samples intraoperatively and continued in six patients after discharge using (OPAT), while 8 were discharged with oral antibiotics. One patient died in immediate post operative period due to generalised sepsis. Another patient died of myocardial infarction 2 years after DAIR. 12 (85.7%) patients are doing well with regular followup (Mean 20 months) in clinics. CONCLUSIONS. With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option in PJI in hip and knee replacements compared to one or two stage revisions with the implications. But published Data in contemporary literature is predominantly from specialized centers. Our small series provides a perspective of early to mid term results of DAIR from a DGH

Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of aspirin may represent an acceptable compromise in these patients