Aims

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.

Aims

Despite higher rates of revision after total hip arthroplasty (THA) being reported for uncemented stems in patients aged > 75 years, they are frequently used in this age group. Increased mortality after cemented fixation is often used as a justification, but recent data do not confirm this association. The aim of this study was to investigate the influence of the design of the stem and the type of fixation on the rate of revision and immediate postoperative mortality, focusing on the age and sex of the patients.

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p < 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort. Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n. 0. = 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n. 3. = 28,637). The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p<0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p>0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2]. “Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate

Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using aspirin as chemical thromboprophylaxis. The 30-day and 90-day mortality after primary total hip arthroplasty was zero. We compare this with that reported previously from our unit without using chemical thromboprophylaxis. With the introduction of routine aspirin thromboprophylaxis, deaths from cardiovascular causes have dropped from 0.75% to zero. These results demonstrate that there is a strong argument for the routine administration of aspirin after elective total hip replacement

Pre-operative templating has become an essential aspect of pre-operative preparation for elective total hip replacement. The techniques involved have evolved from acetates used with analogue radiographs to digital processes. This study audits the accuracy of the TraumaCad software in total hip replacement since its introduction at two centres in the same trust. The pre and post-operative radiographs of 40 patients undergoing total hip replacement by a single surgeon at a district general hospital were retrospectively reviewed. Patients that had templating of their digital Picture Archiving and Communications Systems (PACS) pelvic images using the TraumaCad software programme (Orthocrat Ltd, Petach-Tikva, Israel) were included. The templated acetabular component and femoral stem was compared to the actual size of acetabular and femoral prostheses inserted at surgery. The acetabulum was accurately templated in 38.9% of the hips and within ± 1 size in a further 44.4% (total 83.3%). The femoral stem size was accurate in 27.8% of the hips and within ± 1 size in a further 52.8% of the hips (total 80.6%). Such a variation is likely due to the variable positioning of the calibration ball. TraumaCad is a useful tool in the pre-operative templating of hips successfully predicting the prosthesis components within ± 1 size in the majority of hips studied. However, it should not be relied upon as an absolute measurement of the size of prosthesis to be used, rather be used as a suitable guide to intra-operative stages such as the femoral neck cut position

To compare the actual with the reported incidence of pressure sores to determine the accuracy of data (classification errors) and completeness of data (differences between manual and computer generated figures), retrospective data was collected regarding pressure sore rates following primary elective total hip arthroplasty operations carried out in 2001. Pressure sores rates were noted by nursing staff and entered into a computer database. Four consultant orthopaedic surgeons were involved, across 2 sites – 1 NHS (PRH) and 1 local private hospital. Preliminary audit reports indicated an alarmingly high pressure sore rate across the two units – 17/172 (9.9%) PRH and 23/71 (32.4%) private hospital. Two major errors were revealed. In terms of accuracy of data, grade 1 areas (erythema without active ulceration) were included at both sites. These are only potential sites of pressure sores and should not have been used to calculate actual pressure sore rate. In terms of completeness of data, manual verification of the number of operations performed revealed a discrepancy between the theatres’ logbook entries and private unit computer figures. 97 rather than 71 operations were performed. There was no such discrepancy at the NHS site. The data was reanalysed to obtain the actual pressure sore rate. For the NHS unit, grade 1areas were subtracted, causing the rate to fall from 32.4% to 1.0%. The two errors caused a dramatic and significant difference between reported and actual pressure sore rate. Poor data collection leads to inaccurate audit, leading to inappropriate management. The concern is that similar errors, accumulated across key complication targets and specialities, will have a profound impact on NHS star ratings

Elective orthopaedic procedures, and particularly total hip arthroplasty (THA), in octogenarians and nonagenarians patients are burdened of several implications. Besides the comorbidities and the anesthesiological issues, legal and ethical implications are present. Some literature data show the clinical improvement of THA in elderly patient but the psychological aspects are not yet evaluated. Aim of this study is to evaluate the clinical aspects and the psychological impact in daily living in octogenarians and nonagenarians patients addressing THA.

We conducted a retrospective evaluation of 81 THA in 81 patients of age more than 85 years with a minimum follow-up of 6 months. Clinical aspects were evaluated using the Hip disability and Osteoarthritis Outcome Score (HOOS). The psychological issues were evaluated with the Short Form 12 (SF-12) using both the Physical Component Summary (PCS) and the Mental Component Summary (MCS). From the starter cohort of 81 patients, 8 patients were died for causes unrelated to surgery, 13 were lost to follow-up, 1 patient was revised for periprosthetic fracture; 59 patients composed the final cohort. Mean HOOS rased from 18,07 ± 17,81 to 92,36 ± 5,74 with statistically significant distribution both in the global score than in all of the different subscales. The PCS raised from 26,81 ± 10,81 to 51,86 ± 4,45 and The MCS raised from 34,84 ± 10,81 to 56,70 ± 5,04, but none of them showed a statistically significant distribution. THA in octogenarians and nonagenarians patients could be a safe procedure with positive results for clinical and psychological aspects.

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on preoperative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

Enhanced recovery pathways (ERPs) utilise multimodal rehabilitation techniques to reduce post-operative pain and accelerate the rehabilitation process following surgery. Originally described following elective colonic surgery enhanced recovery pathways have gained increasing use following elective hip and knee joint replacement in recent years. Early studies have indicated that enhanced recovery pathways can reduce length of hospital stay, reduce complications and improve cost-effectiveness of joint replacement surgery. Despite this growing evidence base uptake has been slow in certain centres and many surgeons are yet to utilise enhanced recovery pathways in their practice. We look at the process and effects of implementing an enhanced recovery pathway following total hip replacement surgery at a district general hospital in the United Kingdom. A retrospective study was initially undertaken over a four-month period to assess patient demographics, length of stay, time to physiotherapy and complication rates including re-admission within 28 days. Based on national recommendations an enhanced recovery pathway protocol was then implemented for an elective total hip replacement list. Inclusion criteria were elective patients undergoing primary total hip replacement (THR) surgery. The pathway included pre-operative nutrition optimisation, 4mg ondansetron, 8mg dexamethasone and 1g tranexamic acid at induction and 150mL ropivacaine HCL 0.2%, 30mg ketorolac and adrenaline (RKA) mix infiltration to joint capsule, external rotators, gluteus tendon, iliotibial band, soft-tissues and skin around the hip joint. The patient was mobilised four-hours after surgery where possible and aimed to be discharged once mobile and pain was under control. Following implementation a prospective study was undertaken to compare patient demographics, length of stay and complication rates including re-admission within 28 days. 34 patients met the inclusion criteria and were included in each group pre and post-enhanced recovery pathway. Following implementation of an enhanced recovery pathway mean length of stay decreased from 5.4 days to 3.5 days (CI 1.94, p < 0.0001). Sub-group analysis based on ASA grade revealed that this reduction in length of stay was most pronounced in ASA 1 patients with mean length of stay reduced from 5.0 days to 3.2 days (CI 1.83, p < 0.0001). There was no significant change in the number of complications or re-admission rates following enhanced recovery pathway. The enhanced recovery pathway was quick and easy to implement with co-ordination between surgeons, anaesthetist, nursing staff and patients. This observational study of consecutive primary total hip replacement patients shows a substantial reduction in length of stay with no change in complication rates after the introduction of a multimodal enhanced recovery protocol. Both of these factors reduce hospital costs for elective THR patients and may improve patient experiences

During the last decade primary total hip arthroplasty surgery (THA) has increased with 30% in Sweden. Current law guarantees the patient a right to treatment within 90 days. The public health system has had difficulties meeting the increasing demand. Therefore, in 2012 a systematic review of the patients planned for THA was initiated at Sahlgrenska University Hospital's joint replacement unit. In late 2013 the value-based health care (VBHC) management was introduced in our unit.

In 2012 a systematic approach based on the Fast-Track concept was implemented in the joint replacement unit. In 2013 a workgroup consisting of health care professionals involved in the treatment of THA patients was created to improve chosen outcome parameters.

During 2011–2016 the number of elective THA has increased from 317 to 486. The cost per patient has decreased from 75,000 SEK to 65,000 SEK. Length of stay has decreased from 5.9 days to 2.5 days. Satisfaction with outcome of surgery one year after THA increased from 76% to 88%. The number of adverse events decreased from 29% to 11%. Number of re-operations within 2 years decreased from 2,7% to 1,9%.

Fast-Track and VBHC management was initially received with modest enthusiasm in our unit, and was regarded as means to increase production whilst possibly endanger the well-being of the patients. By using continuous feedback using the data collected it was possible to effectively communicate to patients and caregivers that the patients benefitted from the implementation.

VBHC primary aim is to improve patient outcomes and synergetically improve cost and process measurements. This should be appealing to both caregivers and administrators.

Focusing on improvement of outcomes after THA combined with VBHC management has contributed to improvement in quality of care and availability of treatment whilst decreasing cost per patient.

Previous reports have indicated that elderly patients suffer more operative complications than younger patients undergoing total hip arthroplasty (THR)

We reviewed 46 consecutive patients over 85 years of age at the time of THR. All patients were at least 3 years post-op at the time of review. Pre and post operative D’Aubigne-Postel Hip Scores were assigned. Length of stay, transfusion rates, intra-operative blood loss and patient satisfaction were also noted. Statistical comparisons were mode with a control group of patients, average age 66.3 years.

The average age at the time of operation was 86.6 (range 85–92) years. The average follow up was 52.8 (range 38–86) months. The average hospital stay was 21.1 (range 12–40, median 18) days. Pre-operative D’Aubigne-Postel Score averaged 8.4 (range 1–14) points, post-operative D’Aubigne-Postel Score averaged 13.1 (range 9–18) points. Subjective satisfaction was high. There were no operative complications and no dislocations during the follow up period. There were no deaths within one year of surgery. Four of the 45 patients died during the 3 year follow up period.

When compared to the control group, patients over the age of 85 years had an increased intra-operative blood loss, p< 0.001, they also had an increased blood transfusion at rate, p=0.0005. Patients over the age of 85 remained in hospital longer, p=0.0002. Comparing D’Aubigne-Postel Score, patients over the age of 85 years benefited as much as the control group, p=0.0001.

We conclude that THR is the over 85 years old patients is a safe procedure and yields good functional results.

Introduction

Patients undergoing total hip arthroplasty (THA) stand in the danger, a particularly high risk for venous thromboembolism (VTE). Fondaparinux and edoxaban, which inhibit FXa, indirectly and directly, respectively, have been used for prevention of VTE after THA in Japan. The aim of this study was to compare the efficacy of fondaparinux and edoxaban for VTE after elective THA in Japanese patients.

Introduction: The national comparative audit in 2007 of blood use in primary elective hip replacement, showed a 25% transfusion rate. Of those 93% received two or more units. Orthopaedic surgeons are large users of blood, so reducing blood use, should save costs and reduce risk from unnecessary donor exposure.

Methods: Over two years 221 consecutive primary total hip replacements were performed, on 84 male and 137 female patients, average age 70 years (42–91yrs). For each the Haematinics cell salvage system was used. Throughout the surgery the cell salvage system was used. At the end of the operation all swabs were washed, the washings were salvaged. Iodine/peroxide contaminated washing and swabs were discarded.

Results: Were we using blood at the level suggested by the comparative audit, 55 patients would have received an average of 2.4 units (132 units total). The actual number of patients transfused was 12, receiving an average of two units (24 units total). This is 108 units less with 43 fewer patients receiving allogenic blood. Using a test of proportions using the Normal distribution then the significance probability is extremely small (SP< 0.001) indicating that this group of patients had a significantly smaller number of transfusions than would be expected compared with the National Average. The transfused patients were older (78.9 vs. 69.8, p< 0.01), had a greater Hb drop (45 g/l vs. 31.2 g/l, p< 0.01), had a lower pre-op Hb (121.3 g/l vs. 138 g/l, p< 0.001), and a greater length of stay (12.8 days vs. 5.8 days, p< 0.05). Gender was not significant.

Discussion: Using the cell salvage system leads to a significant reduction in allogenic blood use. It may not be cost neutral once the use of disposables is factored in, but may represent a useful tool to cost effectively reduce allogenic blood use.

Introduction: Venous thromboembolism is a major cause of morbidity and mortality in hospitalised patients and patients undergoing major orthopaedic surgery are at high risk from venous thromboembolism. Thromboprophylaxis, both mechanical and chemical, is commonly administrated to reduce fatality from thromboembolism after surgery. However, there is no convincing evidence in the literature demonstrating that routine chemothromboprophylaxis reduces death rates from pulmonary embolus. Furthermore, it is unclear from the literature which thromboprophylactic agent, if any, should be used.

Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that aspirin, which is a low cost prophylactic agent, is effective in preventing DVT and PE after orthopaedic surgery. The aim of this study was to determine the 90-day mortality rate after THR using aspirin as a prophylactic agent.

Patients and Methods: Between 2003–2006, 2,286 patients underwent primary THR and 372 patients underwent revision hip replacement (RHR). Routine chemothromboprophylaxis consisting of aspirin 75mg daily for 6 weeks. In addition all patients were treated with anti-thromboembolic stockings. 40mg of subcutaneous clexane, in lieu of aspirin, was given daily to all patients who had previously suffered from a pulmonary embolus or deep venous thrombosis. Patients who died within 90 days of surgery had their death certificates examined. Retrieval at 90 days with regard to death was 100%.

Results:

Primary THR

One patient (0.04%) died within 30 days of surgery and a further 3 (0.13%) died between day 30 and day 90, giving a total mortality at 90 days of 0.17% (4/2,286). One patient (0.04%) died from PE and the other 3 patients (0.13%) died from non-vascular causes.

Discussion: This study found that the 30-day mortality rate for primary THR and RHR was 0.08% and the 90-day mortality rate was 0.23%. In this study, there was only one death from PE and no deaths from arterial complications. Therefore, although NICE guidelines suggest the use of heparin, this study found that routine aspirin administration is beneficial in protecting against early death after THR because of both thromboembolism and adverse arterial events.

Background

Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR.

Introduction

Previous systematic reviews have shown that patients experience low physical activity levels following total hip replacement (THR). However no previous systematic reviews have examined the changes between pre- and post-operative physical activity levels.

Aims. Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. Methods. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. Results. We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. Conclusion. Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care. Cite this article: Bone Joint J 2022;104-B(9):1052–1059

Introduction. The effect of spine-pelvis position and motion on hip arthroplasty function has been increasingly appreciated in the past several years. Some authors have stressed the importance of using precision technologies for component placement while others have advocated the use of dual mobility articulations or large bearings and lateralized liners in patients with fused lumbar spines. The current study assesses the prevalence of stiff and fused spines in an elective total hip arthroplasty population. Methods. One hundred and forty-nine patients undergoing elective total hip arthroplasty were assessed preoperatively with CT (computed tomography) and functional radiographs for the purpose of CT based planning and intraoperative navigation of total hip arthroplasty (HipXpert System, Surgical Planning Associates, Inc., Boston, MA). The functional radiographs included standing and sitting lateral images (EOS Imaging, SA, Paris, France). Patients were assessed for supine, standing and sitting pelvic tilt (PT) and change in sacral slope (SS). Spine stiffness was defined by a change in sacral slope (SS) of less than or equal to 10 degrees on the standing to sitting lateral radiographs according to Luthringer et al JOA 2019. Results. Of these 149 patients, 2 (1.5%) had been previously treated by instrumented lumbar fusion. Thirty-nine additional patients (26.1%) had stiff spines as defined by a change in sacral slope of less than 10 degrees from standing to sitting. The mean supine PT measured by CT scan was 3.46 degrees of anterior PT which is similar to previously described in the literature. The mean supine PT in stiff spine patients measured 1.5 degrees of anterior tilt which was not statistically significant. The mean standing pelvic tilt measured 0.0 degrees in the all patients and −4.3 degrees in stiff spine patients. The mean sitting pelvic tilt was −18.9 degrees in the entire cohort and −11.3 degrees in the stiff spine patients. The difference in pelvic tilt between these two groups was statistically significant with p-values of 0.002 and 0.006, respectively. Discussion and Conclusion. Although the incidence of formal instrumented spine fusion was low in this cohort (1.5%), the incidence of spine stiffness was very high at 27.6%. Given that hip instability has been decreasing owing to a variety of techniques including larger bearings, intraoperative radiography, and intraoperative precision technologies, advocacy for the use of dual mobility implants simply for a history of spine fusion does not appear to be logical given that most stiff spines have not had a surgical fusion

Aims. To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage. Methods. We included 53,099 patients with cemented THA due to osteoarthritis from the Swedish Hip Arthroplasty Registry for model derivation and internal validation, as well as 125,428 patients from England and Wales recorded in the National Joint Register for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey (NJR) for external model validation. A model was developed using a bootstrap ranking procedure with a least absolute shrinkage and selection operator (LASSO) logistic regression model combined with piecewise linear regression. Discriminative ability was evaluated by the area under the receiver operating characteristic curve (AUC). Calibration belt plots were used to assess model calibration. Results. A main effects model combining age, sex, American Society for Anesthesiologists (ASA) class, the presence of cancer, diseases of the central nervous system, kidney disease, and diagnosed obesity had good discrimination, both internally (AUC = 0.78, 95% confidence interval (CI) 0.75 to 0.81) and externally (AUC = 0.75, 95% CI 0.73 to 0.76). This model was superior to traditional models based on the Charlson (AUC = 0.66, 95% CI 0.62 to 0.70) and Elixhauser (AUC = 0.64, 95% CI 0.59 to 0.68) comorbidity indices. The model was well calibrated for predicted probabilities up to 5%. Conclusion. We developed a parsimonious model that may facilitate individualized risk assessment prior to one of the most common surgical interventions. We have published a web calculator to aid clinical decision-making. Cite this article: Bone Joint J 2021;103-B(3):469–478