While indications for total knee (TKA) and hip arthroplasty (THA) have expanded over the last 35 years, implant labeling has largely remained stagnant, with conditions including obesity, developmental dysplasia, and many others (Table 1) still considered as contraindications. Implant labeling has not co-evolved with surgical indications, as most orthopaedic implants are cleared through the 510(k) process, which conserves the labeling of the predicate device. While surgeons can legally use devices for off-label indications, the scrutiny regarding off-label use of orthopaedic implants has intensified. The objective of this study was to determine the incidence of off-label use at our institution, define the risk in terms of revision rate associated with off-label use, and to compare activity level, functional outcomes, and general health outcomes for on- and off-label TKA and THA patients. Patients who underwent primary TKA or THA at a large academic tertiary referral center between January 1, 2010 and June 30, 2010 were considered for the study (n = 705). Of this cohort, a convenience sample of 283 patients were selected for the study based on the presence of baseline outcomes data. Patients were contacted via mail and/or phone to collect details regarding potential revision surgeries, UCLA activity scores, short form-12 (SF-12), Knee Injury and Osteoarthritis Outcome Score (KOOS) or Hip Disability and Osteoarthritis Outcome Score (HOOS). Using labeled contraindications from the product inserts from multiple orthopaedic implant manufacturers, procedures were categorized as on-label or off-label. Outcomes including revision rate, activity score, and SF-12, KOOS, and HOOS scores were adjusted for age, gender, and BMI by fitting a logistic model and analyzed using the Wald chi-square test (SPSS, Chicago, IL).Introduction:
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Primary total knee arthroplasty (TKA) is associated with perioperative bleeding, and some patients will require allogenic blood transfusion during their inpatient admission. While blood safety has improved in the last several decades, blood transfusion still carries significant complications and costs. Transfusion indications and alternative methods of blood conservation are being explored. However, there is limited nationally representative data on allogenic blood product utilization among TKA patients, and its associated outcomes and financial burden. The purpose of this study was to use a national administrative database to investigate the trends in utilization and outcomes (i.e. in-hospital mortality, length of stay, admission costs, acute complications) of allogenic blood transfusion in primary TKA patients. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was utilized. Primary TKA (ICD-9-CM 81.54) cases from 2000 to 2009 were retrospectively queried (n = 4,544,999; weighted national frequency). A total of 67,841 admissions were excluded (Figure 1). The remaining 4,477,158 cases were separated into two study cohorts: (1) patients transfused with allogenic blood products (red blood cells, platelets, serum) (n = 540,270) and (2) patients not transfused (n = 3,936,888). Multivariable regression and generalized estimating equations were used to examine the effect of transfusion on outcomes, adjusting for patient/hospital characteristics and comorbidity.Introduction:
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Multimodal analgesia protocols for pain control following total joint arthroplasty can reduce post-operative pain, allow early mobilisation and early discharge from hospital. This study analyses the achievement of functional milestones, patient satisfaction, length of stay and adverse outcomes using a multimodal analgesia protocol in total joint arthroplasty. All patients planned for elective hip and knee arthroplasty in a NSW teaching hospital under one surgeon between July 2007 and January 2009 were included in this prospective study. Patients undergoing revision surgery, bilateral arthroplasty or total hip arthroplasty for fractures were excluded. Unless contraindicated, all patients followed the multimodal analgesia protocol based on the local infiltration analgesia technique described by Kerr and Kohan. Patient demographics, post operation milestones, visual analogue pain scores (VAS), narcotic consumption, length of stay, discharge destination, patient satisfaction scores and adverse outcomes. Nineteen patients (13 female and 6 male) with an average age 67 years and BMI 33 had total hip arthroplasty surgery. 84% (16/19) ambulated within six hours post operation. 47% (9/19) of patients were discharged home by day 3 post operation (1/19 on day 1, 5/19 on day 2, 3/19 on day 3). Average day post operation for discharge home was 4.5 days. Thirty-one patients (17 female and 14 male) with an average age 68 years and BMI 33 had total knee arthroplasty surgery. 90% (28/31) ambulated within six hours after surgery. 71% (22/31) of patients were discharged home by day three post operation (6/31 on day 1, 8/31 on day 2 and 8/31 on day 3). Average day post operation for discharge home was four days. Ten patients required morphine in addition to protocol analgesia. VAS scores (1 to 10) averaged 3.2 day one post op and 2.6 prior to discharge. Three patients developed nausea and vomiting and one patient developed urinary retention. No infections, DVTs or other adverse effects occurred in either hip or knee arthroplasty groups. Majority of patients were very satisfied according to 24 hour post op pain management survey and six week post op patient satisfaction survey. Local infiltration analgesia in knee and hip arthroplasty surgery is a safe, well-tolerated and effective form of pain control allowing early mobilisation and early discharge from hospital (1,2). This protocol has been successfully implemented in a public hospital.Outcomes measurements included
