Controversy exists regarding the use of closed suction drainage in Total hip and Total knee replacement. A retrospective study on hip and knee arthroplasties was carried out to assess the efficacy of postoperative wound drainage. Twenty-five consecutive hip replacements and twenty -five consecutive knee replacements had closed wound drainage for twenty-four to forty-eight hours after the surgery while twenty-five patients in each group did not. All operations were carried out using similar operative technique under the care of a single surgical team. Perioperative protocol for thromboprophyaxis, antibiotics, dressing and postoperative mobilisation was similar in all the patients. Thromboprophylaxis consisted of 5000 units of Fragmin daily for five days and 75 mg of Aspirin for six weeks from the day of operation. Antibiotic prophylaxis consisted of three doses of intravenous Cefuroxime perioperatively. The hospital records including the physiotherapy and nursing notes were used for data collection. Patients were evaluated for preoperative and postoperative haemoglobin levels, the amount of blood transfused, hospital stay, functional outcome in terms of range of motion and complications. The average period of follow -up was one year. The study showed no difference in the drop in haemoglobin levels between the drained and the undrained hips. However, the drained knees had a greater fall in haemoglobin levels postoperatively compared to the undrained. In both hip and knee arthroplasties, a larger volume of blood had to be transfused in patients with drains than those without. There was no difference between the drained and undrained patients in both the hip and knee groups in terms of hospital stay, range of movements and incidence of complications. Our preliminary study suggests that Total hip and Total Knee replacement without the use of postoperative drainage is a safe procedure. The study has financial and clinical implications

Aims

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are.

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

Patients with Paget's Disease of Bone (PDB) more frequently require total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, controversy remains regarding their outcome. This project aims to evaluate the current literature regarding outcomes following THA and TKA in PDB patients.

MEDLINE, EMBASE and Cochrane databases were searched on February 15th, 2022. Inclusion criteria comprised studies evaluating outcomes following THA/TKA in PDB patients. Quality of included studies was assessed using the Newcastle-Ottawa Scale.

19 articles (published between 1976–2022) were included, comprising 58,695 patients (48,766 controls and 10,018 PDB patients), from 209 potentially relevant titles. No study was of high quality. PDB patient pooled mortality was 32.5% at mean 7.8(0.1-20) years following THA and 31.0% at mean 8.5(2-20) years following TKA. PDB patient revision rate was 4.4% at mean 7.2(0-20) years following THA and 2.2% at mean 7.4(2-20) years following TKA. Renal complications, respiratory complications, heterotopic ossification, and surgical site infection were the most common medical and surgical complications.

The largest systematic review, to date, evaluating outcomes following THA and TKA in PDB patients. All functional outcome scores improved. PDB patient revision rate was comparable to UK National Joint Registry. However, there is a significant need for prospective matched case-control studies to robustly compare outcomes in PDB patients with unaffected counterparts.

Aims

Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA.

Background

Frequency of primary total hip (THA) and total knee (TKA) arthroplasty procedures is increasing, with a subsequent rise in revision procedures. This study aims to describe timing and excess surgical mortality associated with revision THA and TKA compared to those on the waiting list.

Aims

Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions.

Introduction

Readmission after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) places a great burden on the health care system. As reimbursement systems place increased emphasis on quality measures such as readmission rates, understanding the causes for readmission becomes increasingly important.

Introduction

Readmission after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) places a great burden on the health care system. As reimbursement systems place increased emphasis on quality measures such as readmission rates, identifying and understanding the most common drivers for readmission becomes increasingly important.

Introduction

The utility and yield of the current practice of routine screening of asymptomatic patients after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) is unclear. The purpose of this prospective survey study was to determine the utility of the routine on year follow up visit primary THA and TKA.

INTRODUCTION

Osteoarthritis (OA) of the hip and the knee has been found to affect sexual activity. Few retrospective studies have investigated the role of total hip replacement on sexual function. We designed a prospective study to evaluate the influence of total hip arthroplasty (THA) and total knee arthroplasty (TKA) on the physical and psychological aspects of sexuality of patients.

Reduced length of stay (LOS) is logistically, economically and physiologically beneficial. Although a high proportion of total joint arthroplasty (TJA) patients are suitable for same day admission (SDA), removable barriers persist in many centres. This study aimed to determine factors limiting SDA and quantify the impact of implementing both SDA and a targeted enhanced recovery programme on length of stay.

This single-centre retrospective cohort study collected data on elective TJA patients aged <60. Qualitative service reviews identified opportunities for optimisation. Improvements were implemented in 2017, including: obtaining consent at the pre-assessment clinic and robustly assessing suitability for SDA. A targeted rapid recovery program was implemented in June 2018. Data was collected prior to changes in 2017, and following changes in 2018.

106 of 108 screened patients were eligible for inclusion. There were no significant between-year differences in baseline health characteristics. Significantly greater proportions of 2018 patients were consented at their pre-assessment clinic (56% vs 8.9%, p<0.001) and assessed as suitable for SDA (94% vs 57.1%, p<0.001). Pre-operative LOS was significantly reduced in 2018 for both total hip replacements (median [IQR]: 0[0,0] vs 1[1,1], p<0.001) and total knee replacements (median [IQR]: 0[0,0] vs 0[0,1], p=0.002). The departmental mean LOS improved from 4.7 days to 3.7 days following SDA. This was further shortened to 3.2 days after introduction of the rapid recovery program.

When a larger proportion of patients were deemed suitable for SDA, this correlated with reduction of LOS. The department now performs above national standards in both of these parameters.

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis.

The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts.

Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care).

General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates.

Our study has determined the response of C-reactive protein (CRP) after total knee replacement (TKR). The peak level occurs on the second postoperative day and is significantly greater than that after total hip replacement (THR). The level returns to normal at similar times after both procedures. The physiological response to TKR as measured by the area under the CRP/ time curve is significantly greater than that after THR. Rising CRP levels after the third postoperative day may indicate a complication of surgery such as infection.

Introduction

There has been much discussion in the literature concerning the possible detrimental effects of metal ion circulating in the body after MOM THR. This study seeks to evaluate the differences in observed Co and Cr levels in blood after TKR and several popular THR options.

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.

Cite this article: Bone Joint J 2024;106-B(2):114–120.

Aims

Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA.

The focus of deep vein thrombosis (DVT) prophylaxis following total joint arthroplasty has shifted in recent years to the reduction of symptomatic pulmonary emboli (PE). The relative infrequency and presumed delayed occurrence of these events has led many to suggest that the risks of more frequent early postoperative complications of treatment, especially bleeding, be weighed against the benefits of thromboembolic prophylaxis. The purpose of this study was to determine the timing and risk factors associated with the development of symptomatic PE following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

A retrospective analysis was performed of all patients diagnosed with a symptomatic pulmonary embolism following THA and TKA performed from January, 2004 to March, 2008. The records of 4706 patients were reviewed who were operated upon by 7 surgeons, and a total of 58 PE were identified. All patients were managed and treated by an anti-coagulation dosing service. Helical CT Scans were used to make the diagnosis of PE.

The overall incidence of PE was 1.2%, with 1.8% occurring in TKAs and 0.5% occurring in THAs. 48 of the 58 PE patients (83%) were women. 33 patients (57%) had unilateral TKA, 14 (24%) had bilateral TKA and 11 (19%) had THA. The average patient age was 65 (range: 44–88) and BMI was 33.8 (range: 24.7–51.9). There was no apparent correlation between age and BMI with incidence of PE. The PE were diagnosed an average of 4 days (range: 1–46) following surgery. 56 of the 58 patients (97%) were diagnosed by the sixth postoperative day. The average INR at the time of diagnosis was 1.7 (range: 1.0–3.0). There were two mortalities (3%), both of which occurred within the first two postoperative days.

The PE in this study occurred predominantly in women undergoing TKA. There appears to be an urgent need to develop an effective prophylaxis program aimed at preventing PE in the early post-operative period and to identify patients at risk of these PE.

Aims: To investigate the efficacy and safety of a new dosage regimen of the oral direct thrombin inhibitor ximelagatran, and its subcutaneous (sc) form melagatran, started in close proximity to surgery. Methods: In a randomised, double-blind, parallel-group study, duration 8–11 days, patients undergoing total hip or knee replacement (THR, n= 1856; TKR, n= 908) received either sc melagatran 2 mg immediately before surgery followed by sc 3 mg in the evening after surgery, and then by oral ximelagatran 24 mg bid as a fixed dose (the ximelagatran group), or sc enoxaparin 40 mg od, started the evening before surgery. Bilateral venography was performed on the final day of treatment. Results: The rate of proximal deep vein thrombosis plus pulmonary embolism was 2.3% in the ximelagatran group vs. 6.3% in the enoxaparin group (p< 0.000002; RRR 63.2%). The total rates of venous thromboembolism (VTE) were 20.3% vs. 26.6%, respectively (p< 0.0003; RRR 23.6%). Cases with symptomatic VTE were rare: 8 in the ximelagatran group and 12 in the enoxaparin group. Bleeding events were more common in the ximelagatran group compared with the enoxaparin group (3.3% vs. 1.2%) as were the transfusion rates (66.8% vs. 61.7%). Importantly, there were no differences in fatal bleeding, critical organ bleeding or bleeding requiring re-operation. Conclusion: Pre-operatively initiated sc melagatran followed by oral ximelagatran was superior in efficacy to enoxaparin in preventing VTE in patients undergoing THR or TKR.

Introduction: Rivaroxaban is a novel, oral, direct Factor Xa inhibitor for the prevention of venous thromboembolism (VTE) after total hip and knee arthroplasty (THA, TKA). The pivotal RECORD trials showed that 35 days’ rivaroxaban significantly reduced total VTE following THA versus both 35-day and 14-day enoxaparin regimens. Following TKA, 14 days’ rivaroxaban significantly reduced total and symptomatic VTE versus 14 days enoxaparin. Major bleeding was similar for rivaroxaban and enoxaparin. An economic model was developed based on these results to assess the cost-effectiveness of rivaroxaban relative to enoxaparin in Sweden.

Methods: The incidence of clinical events and resulting consequences on resource use and quality of life were modelled for rivaroxaban and enoxaparin over 5 years. VTE incidence during the prophylaxis period was based upon RECORD2 (THA) and RECORD3 (TKA) and extrapolated out to 90 days following surgery based on published epidemiological data. These trials were used because they best reflect the treatment length currently applied in clinical practice in Sweden. Recurrent VTE and post-thrombotic syndrome (PTS) beyond 90 days were modelled from published clinical data. Literature indicates that 10% of enoxaparin patients require visits from a district nurse following hospital discharge to administer subcutaneous (sc) enoxaparin, a cost not incurred with oral rivaroxaban. The cost associated with clinical events (major bleed, VTE and PTS) and home care visit was derived from published Swedish sources and expressed in Swedish kroner (SEK). Rivaroxaban and enoxaparin costs were included.

Results: In THA, 35 days’ rivaroxaban produced an additional cost (SEK 119 [€12.59] per patient) versus 14 days enoxaparin. However, rivaroxaban resulted in a gain of quality-adjusted life years (QALYs) and in fewer symptomatic events per patient relative to enoxaparin. This means an extra cost with rivaroxaban of SEK 29,378 (€3,109) per QALY gained and SEK 3,929 (€416) per symptomatic event avoided. Because the cost for treating a VTE range from SEK 12,000 to 30,000, it is less costly to avoid such an event by using rivaroxaban than treating it once it occurs. In TKA, 14 days’ rivaroxaban produced savings of SEK 873 (€92) per patient versus 14 days’ enoxaparin, as well as an improvement in QALYs and a reduction in symptomatic VTE events. Consequently, rivaroxaban was both more effective and less costly. Extensive sensitivity analyses showed that these results persist in a clear majority of situations.

Conclusion: The economic analysis showed that by reducing VTE, and providing an oral alternative to sc enoxaparin, oral rivaroxaban has the potential to significantly improve health outcomes in Sweden at a slightly higher (in THA) or lower (in TKA) cost than existing VTE prophylaxis.