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

The National Hip Fracture Database (NHFD) started collecting data on peri-prosthetic femoral fractures (PPFF) in December 2019. We reviewed the data from the first year of data collection to describe the patients being admitted with PPFF and the care they received according to established Key Performance Indicators (KPIs) used in hip fracture surgery. We performed a retrospective review of the NHFD between 1 January and 31 December 2020. Analyses consisted of the summary statistics used to generate the NHFD annual report. Of the KPIs used in hip fracture, data were available for PPFF on time to assessment by a geriatrician (KPI 1), time to theatre (if applicable) (KPI 2), and mobilisation the day after surgery (if applicable) (KPI 4). There were 2,411 PPFF fractures around a hip or knee replacement reported out of a total of 2,606 PPFF. Of the 171 hospitals reporting data to the NHFD, 135 reported at least one. The median number of fractures per hospital was 14 (IQR 8, 25, range 1 to 110). The median age of patients was 84 (range 60 to 104) and 1,604 (67%) patients were female. Of the 1,850 occasions a time to geriatrician review was documented, review within 72 hours was achieved on 89.2% of occasions. Of the 1,973 patients who underwent operative interventions, 546 patients went to theatre before the 36-hour target (28.4%). Of patients who had surgery 1,323 (67.4%) were mobilised the following day. In the first year collecting data on PPFF we can give the first idea of the incidence of these life changing injuries. Whilst geriatrician review with 72 hours was achieved in a high proportion of cases nationally, our data suggest fewer patients are mobilised the day after surgery. Notably, only 28.4% of patients who were managed operatively went to theatre within 36 hours of admission. We provide the first insight into the incidence and management of these injuries

Aims. The direct anterior (DA) approach has been associated with rapid patient recovery after total hip arthroplasty (THA) but may be associated with more frequent femoral complications including implant loosening. The objective of this study was to determine whether the addition of a collar to the femoral stem affects implant migration, patient activity, and patient function following primary THA using the DA approach. Methods. Patients were randomized to either a collared (n = 23) or collarless (n = 26) cementless femoral stem implanted using the DA approach. Canal fill ratio (CFR) was measured on the first postoperative radiographs. Patients underwent a supine radiostereometric analysis (RSA) exam postoperatively on the day of surgery and at two, four, six, 12, 26, and 52 weeks postoperatively. Patient-reported outcome measures (Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the 12-item Short Form Health Survey Mental and Physical Score, and University of California, Los Angeles (UCLA) Activity Score) were measured preoperatively and at each post-surgery clinic visit. Activity and function were also measured as the weekly average step count recorded by an activity tracker, and an instrumented timed up-and-go (TUG) test in clinic, respectively. Results. Comparing the RSA between the day of surgery baseline exam to two weeks postoperatively, subsidence was significantly lower (mean difference 2.23 mm (SD 0.71), p = 0.023) with collared stems, though these patients had a greater CFR (p = 0.048). There was no difference (p = 0.426) in subsidence between stems from a two-week baseline through to one year postoperatively. There were no clinically relevant differences in PROMs; and there was no difference in the change in activity (p = 0.078) or the change in functional capacity (p = 0.664) between the collared stem group and the collarless stem group at any timepoint. Conclusion. Presence of a collar on the femoral stem resulted in reduced subsidence during the first two postoperative weeks following primary THA using the DA approach. However, the clinical implications are unclear, and larger studies examining patient activity and outcomes are required. Cite this article: Bone Joint J 2020;102-B(12):1654–1661

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

The interest in day-case hip arthroplasty is increasing; however, there are conflicting results regarding readmission risk, and little is known about patients’ attitude towards day-case surgery. We aimed to investigate differences in 30-day readmission rates between day-case patients and single-overnight-stay patients following total hip arthroplasty (THA) and explore patients’ attitude towards day-case surgery. From the Danish National Patient Register we identified 29,486 THAs (1353 day-case THAs and 28,133 single-overnight-stay THAs) performed between 2010 and 2020. Day-case surgery was defined as discharge on the day-of-surgery. Overnight admissions within 30 days of surgery were considered readmissions. Differences in readmission rates between day-case and single-overnight-stay patients were investigated using logistic regression adjusted for patient characteristics and year of surgery. In a single-center descriptive study, 2395 hip arthroplasty patients from 2016 to start-2023 answered a questionnaire on patient characteristics, attitude towards day-case surgery and patient-reported outcome measures (PROM). The overall 30-day readmission rate was 4.4% (CI: 4.2–4.6%) with no difference between day-case (4.4%) and single-overnight-stay THAs (4.4%) (odds-ratio: 1.2 [CI: 0.91–1.6]). In the descriptive study answers to the question whether patients were interested in being discharged on the day of surgery, were: “Yes” = 41%, “Do not know” = 20%, “No” = 39%. Patients responding “No” had lower preoperative PROM-scores, were older (“No” = 70.2 y vs. “Yes” = 65.3 y), and more often female (“No” = 72% vs. “Yes” = 52% female). Based on nationwide data from 2010–2020, day-case THA patients were not more likely to be readmitted compared to single-overnight-stay patients. However, most patients were not positive towards day-case surgery. While surgeons may consider day-case surgery to be safe, patients are not intuitively positive, indicating an attitude mismatch. To achieve high success rate and patient satisfaction in day-case surgery, shared-decision making initiatives within day-case surgery are needed

Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive . Staphylococcus Aureus. (MSSA) is the most frequent organism, and the majority are endogenous. Nasal MSSA colonisation is a proven risk factor for S. aureus infection. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI. Our hospital trust introduced MSSA screening and decolonisation prior to hip and knee arthroplasty in 2010. Data was prospectively collected since 2013, including all MSSA carriers, decolonisation treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used. During the study period 15,958 primary hip and knee replacements were performed. 3,200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1,210 neomycin and 1,221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P<0.0001). There was no difference in S. aureus PJI rates (P=0.452). Of those negative at original screening 9.1% were positive on the day of surgery (1,164/12,758). MSSA decolonisation is an effective method to decrease PJI rates but there is little research into the best treatment. Both mupirocin and neomycin are more effective than octenidine at achieving MSSA decolonisation. There was poor correlation between the MSSA status after treatment and PJI rates. There is debate if treatment should be targeted by screening or if all patients she be treated without screening. Global decolonisation without screening is supported by the 26.7% of carriers that were negative at original screening in our study. Further research is needed comparing decolonisation treatments to reduce PJI rates and avoid the risk of drug resistance

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

Aims. The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). Methods. In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. Results. Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. Conclusion. These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82–89

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

Aims. We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon. Methods. We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. Results. Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit. Conclusion. Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA. Cite this article: Bone Jt Open 2021;2(2):93–102

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. Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. Patients and Methods. A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. Results. TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). Conclusion. In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis

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Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

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In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance.

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The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.

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The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA).

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Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture.

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Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures.

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This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice.

Introduction. Recent literature has sought to quantify pre-operative work associated with total joint arthroplasty. These studies have utilized surveys or self-reported time logs to estimate the Pre-op Optimization Work (POW) completed by the surgical team. The purpose of this study was to objectively quantify POW associated with total hip arthroplasty (THA) using electronic medical record (EMR) activity audit logs. Methods. Retrospective analysis of EMR activity for 4 arthroplasty surgeons and their clinical staff was collected for 100 consecutive THA cases (25 per surgeon). Clinical informatics data was generated using EMR activity audit logs for pre-THA activity. Every action and mouse-click within a patient's chart was recorded for each team member. The time between mouse-clicks was calculated and summed for each user. Times exceeding five minutes without activity were assumed to reflect inactivity and excluded. Descriptive statistics were used to estimate the POW associated with THA preparation. Results. The mean number of days for pre-THA time period was70.7 (SD43.9; range: 8–175days). During this period, the mean time spent in each patient's chart was 75.5 minutes (SD50.75) minutes. Surgeon's POW in the medical record accounted for 7.3(SD6.7) of these minutes. Much of the work was conducted by nurses (47.0 minutes, SD43.4), physician extenders (10.8 minutes, SD 13.1), and qualified office staff/technicians (10.4 minutes, SD14.9). The majority of work captured in the EMR activity log was associated with medication review, patient optimization, documentation of necessary medical clearances, ordersets, patient communication, and prior authorization requests. Conclusion. A considerable amount of preoperative work is required between the clinic date a patient decides to pursue THA and the day prior to surgery. These retrospective electronic time stamp measurements should represent the absolute minimum time required for surgical preparation