Aims

The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana).

Fast-track THA and TKA is a dynamic process combining clinical and logistical enhancements to ensure the best outcome for all patients regarding faster early functional recovery and reduced morbidity. Focus is on reducing convalescence by ensuring a smooth pathway with the best available clinical treatment from admission to discharge – and beyond. Main focus areas include pain treatment, mobilization, organizational aspects, traditions, and care principles. Outcome is typically evaluated as: a) length of stay in hospital (LOS), patient satisfaction, and reduced convalescence in the form of earlier achievement of functional milestones; b) safety aspects (reduced morbidity and mortality in the form of complications and readmissions in general and dislocations/manipulations in specific); c) feasibility (can the track be applied to other subgroups of patients, i.e. bilaterals or revisions?); and d) economic savings. Favorable outcomes regarding all these parameters have been documented for fast-track THA and TKA which has also resulted in the development of a Rapid Recovery Programme (Biomet).

LOS is now 1–2 days for unselected patients in leading departments with few readmissions, high patient satisfaction and economic savings. In Denmark, the nationwide median LOS is now 4 days and improved logistic features include homogeneous entities, regular staff, high level of continuity, preoperative information including intended LOS, admission on the day of surgery and functional discharge criteria. The improved clinical features include both intraoperative (spinal anesthesia, local infiltration analgesia (LIA), plans for fluid therapy, small standard incisions, no drains, compression bandages and cooling) and postoperative (deep venous thrombosis prophylaxis starting 6–8 hours postoperatively, multimodal opioid-sparing analgesia, early mobilization and discharge when functional criteria are met) facilitating early rehabilitation and discharge.

Future challenges include identification of high-pain responders to improve multimodal pain treatment; identification of high-risk patients regarding complications in fast-track set-ups; how to reduce postoperative cognitive dysfunction; how to reduce orthostatic intolerance; and when how and to whom to initiate and give rehabilitation.

The purpose of this study was to investigate whether a gender-specific high-flexion posterior-stabilised (PS) total knee replacement (TKR) would offer advantages over a high-flex PS TKR regarding range of movement (ROM), ‘feel’ of the knee, pain and satisfaction, as well as during activity. A total of 24 female patients with bilateral osteoarthritis entered this prospective, blind randomised trial in which they received a high-flex PS TKR in one knee and a gender-specific high-flexion PS TKR in the other knee. At follow-up, patients were assessed clinically measuring ROM, and questioned about pain, satisfaction and daily ‘feel’ of each knee. Patients underwent gait analysis pre-operatively and at one year, which yielded kinematic, kinetic and temporospatial parameters indicative of knee function during gait. At final follow-up we found no statistically significant differences in ROM (p = 0.82). The median pain score was 0 (0 to 8) in both groups (p = 0.95). The median satisfaction score was 9 (4 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.98). The median ‘feel’ score was 9 (3 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.66). Gait analysis showed no statistically significant differences between the two prosthetic designs in any kinematic, kinetic or temporospatial parameters.

Both designs produced good clinical results with significant improvements in several gait parameters without evidence of any advantage in the gender-specific design.

Bilateral simultaneous total knee replacement (TKR) has been considered by some to be associated with increased morbidity and mortality. Our study analysed the outcome of 150 consecutive, but selected, bilateral simultaneous TKRs and compared them with that of 271 unilateral TKRs in a standardised fast-track setting. The procedures were performed between 2003 and 2009.

Apart from staying longer in hospital (mean 4.7 days (2 to 16) versus 3.3 days (1 to 25)) and requiring more blood transfusions, the outcome at three months and two years was similar or better in the bilateral simultaneous TKR group in regard to morbidity, mortality, satisfaction, the range of movement, pain, the use of a walking aid and the ability to return to work and to perform activities of daily living. Bilateral simultaneous TKR can therefore be performed as a fast-track procedure with excellent results.