Unicompartmental knee arthroplasty (UKA) has been successfully
performed in the United States healthcare system on outpatients.
Despite differences in healthcare structure and financial environment,
we hypothesised that it would be feasible to replicate this success
and perform UKA with safe day of surgery discharge within the NHS,
in the United Kingdom. This has not been reported in any other United
Kingdom centres. We report our experience of implementing a pathway to allow safe
day of surgery discharge following UKA. Data were prospectively
collected on 72 patients who underwent UKA as a day case between
December 2011 and September 2015. Aims
Patients and Methods
Post-traumatic immunosuppression (PTI) after surgery increases vulnerability to nosocomial infections, sepsis, and death. Knee arthroplasty offers a sterile clinical model to characterise PTI and explore its underlying mechanisms. This prospective non-randomised cohort study of primary total knee arthroplasty was approved by the Local Ethics Committee. Exclusion criteria included revision-arthroplasty, pre-existing infections, blood-transfusions, malignancy, and auto-immune disease. 48 recruited patients fell into two groups, the first received unwashed anti-coagulated autologous salvaged blood transfusions after surgery (ASBT cohort, n=25). The second received no salvaged blood transfusions (NSBT cohort, n=18). Venous blood was sampled pre-operatively and within 3–7 days post-operatively. Salvaged blood was sampled at one and six hours post-operatively. Biomarkers of immune status included: interleukins (IL) or cytokines (x15), chemokines (x3), Damage-Associated-Molecular-Patterns (DAMPS) (x5), anti-microbial proteins (x3), CD24, and Sialic-acid-binding-Immunoglobulin-type-Lectin-10 (Siglec-10). Results were expressed as fold-change over pre-operative values. Only significant changes are described.Background
Methods
Electronic PROMs have many potential uses in orthopaedic practice. The primary objective of this three-phase pilot study was to measure uptake using a web-based ePROM system following the introduction of two separate process improvements. 80 consecutive new elective orthopaedic patients in a single surgeon's practice were recruited. Group 1 (n=26) received a reminder letter, Group 2 (n=31) also received a SMS message via mobile or home telephone and Group 3 (n=23) also had access to Tablet Computer in clinic. Overall 79% of patients had Internet access. 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an ePROM score (p=0.02). There was no significant age difference between groups. In Group 3, 94% of patients listed for an operation completed an ePROM score (p=0.006). Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should improve healthcare delivery, but is in its infancy. This pilot study shows that the combination of SMS reminder and access to Tablet Computer within clinic setting enabled 94% of patients listed for an operation to complete a score on a clinical outcomes web-based system. Further process improvements, such as additional staff training and telephone call reminders, may further improve uptake.
In the current austere financial climate within the NHS where local healthcare Trusts are reimbursed in a Payment by Results system it is important that we accurately identify the costs associated with surgical procedures. We retrospectively reviewed data of 589 consecutive patients undergoing lower limb arthroplasty surgery and recorded their age, BMI and co-morbidities. The effect of these parameters on operative duration and length of stay (LOS) was analysed. We demonstrate that for a 1 point increase in BMI we expect LOS to increase by a factor of 2.9% (p<0.0001) and mean theatre time to increase by 1.46 minutes (p<0.0001). We also show that for a l-year increase in age, we expect LOS to increase by a factor of 1.2% (p<0.0001). We have calculated the extra financial costs associated with this and believe that the current OPCS coding system for obesity underestimates the financial impact of increasing BMI and age on lower limb arthroplasty Trusts are being inadequately reimbursed. The results of this study have been used to produce a chart that allows prediction of LOS following lower limb arthroplasty based on BMI and age. We also believe that the data produced is of use in planning operating lists.
Unicompartmental knee replacements offer improved function with more rapid recovery compared to TKR. There is no published experience with introducing this procedure as a day case in the UK. We report on our experience with a new protocol allowing the patient to be discharged on the day of surgery. A new combination of anaesthetic and surgical techniques are employed. Paracetamol, ibuprofen and pregabalin are given pre-operatively. Patients receive a GA and a subsartorial saphenous nerve block is administered under ultrasound control. The surgery is performed using a routine minimally invasive technique. The joint and surrounding tissues are infiltrated with a combination of LA and adrenaline. Wound closure is with subcutaeneous suture and tissue glue. Patients are mobilised on the day of surgery and if comfortable discharged on paracetamol, codeine, ibuprofen, tramadol P.R.N and buprenorphine patch. Length of stay, pain scores, presence of nausea/vomiting, dizziness, drowsiness, post-operative bleeding and patient satisfaction are all recorded. 18 out of 19 patients have been discharged on the day of surgery. All record high satisfaction. Patients can be safely discharged on the day of surgery after UKR with high levels of satisfaction. We believe we are the first unit in the UK to achieve this.
