Prolonged waits for hip and knee arthroplasty have raised questions about the equity of current approaches to waiting list prioritization for those awaiting surgery. We therefore set out to understand key stakeholder (patient and surgeon) preferences for the prioritization of patients awaiting such surgery, in order to guide future waiting list redesign. A combined qualitative/quantitative approach was used. This comprised a Delphi study to first inform which factors patients and surgeons designate as important for prioritization of patients on hip and knee arthroplasty waiting lists, followed by a discrete choice experiment (DCE) to determine how the factors should be weighed against each other. Coefficient values for each included DCE attribute were used to construct a ‘priority score’ (weighted benefit score) that could be used to rank individual patients waiting for surgery based on their respective characteristics.Aims
Methods
The purpose of this study was to compare the
diagnostic accuracy for the detection of infection between the culture of
fluid obtained by sonication (SFC) and the culture of peri-implant
tissues (PITC) in patients with early and
Aim. Restarting elective services presents a challenge to restore and improve many of the planned patient care pathways which have been suspended during the response to the COVID-19 pandemic. A significant backlog of planned elective work has built up representing a considerable volume of patient need. We aimed to investigate the health status, quality of life, and the impact of
Aims. Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods. A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for
Aims. The COVID-19 pandemic led to a national suspension of “non-urgent” elective hip and knee arthroplasty. The study aims to measure the effect of the COVID-19 pandemic on total hip arthroplasty (THA) and total knee arthroplasty (TKA) volume in Scotland. Secondary objectives are to measure the success of restarting elective services and model the time required to bridge the gap left by the first period of suspension. Methods. A retrospective observational study using the Scottish Arthroplasty Project dataset. All patients undergoing elective THAs and TKAs during the period 1 January 2008 to 31 December 2020 were included. A negative binomial regression model using historical case-volume and mid-year population estimates was built to project the future case-volume of THA and TKA in Scotland. The median monthly case volume was calculated for the period 2008 to 2019 (baseline) and compared to the actual monthly case volume for 2020. The time taken to eliminate the deficit was calculated based upon the projected monthly workload and with a potential workload between 100% to 120% of baseline. Results. Compared to the period 2008 to 2019, primary TKA and THA volume fell by 61.1% and 53.6%, respectively. Since restarting elective services, Scottish hospitals have achieved approximately 40% to 50% of baseline monthly activity. With no changes in current workload, by 2021 there would be a reduction of 9,180 and 10,170 for THA and TKA, respectively. Conversely, working at 120% baseline monthly output, it would take over four years to eliminate the deficit for both TKA and THA. Conclusion. This national study demonstrates the significant impact that COVID-19 pandemic has had on overall THA and TKA volume. In the six months after resuming elective services, Scottish hospitals averaged less than 50% normal monthly output. Loss of operating capacity will increase treatment
We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na+), potassium (K+), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported.Aims
Methods
The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs.Aims
Methods
This study aims to evaluate the impact of metabolic syndrome in the setting of obesity on in-hospital outcomes and resource use after total joint replacement (TJR). A retrospective analysis was conducted using the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years and older with obesity (BMI > 30 kg/m2) who underwent primary TJR were included. Patients were stratified into two groups with and without metabolic syndrome. The inverse probability of treatment weighting (IPTW) method was used to balance covariates.Aims
Methods
The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery. We performed an analysis of the mandatory prospective national registry of all independent and publicly funded hip, knee, shoulder, elbow, and ankle replacements in England, Wales, and Northern Ireland between January 2019 and December 2022 inclusive, totalling 729,642 operations. The deficit was calculated per year compared to a continuation of 2019 volume. Total deficit of cases between 2020 to 2022 was expressed as a percentage of 2019 volume. Sub-analyses were performed based on procedure type, country, and unit sector.Aims
Methods
The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L.Aims
Methods
The aim of this study was to evaluate the diagnostic accuracy of the absolute synovial polymorphonuclear neutrophil cell (PMN) count for the diagnosis or exclusion of periprosthetic joint infection (PJI) after total hip (THA) or knee arthroplasty (TKA). In this retrospective cohort study, 147 consecutive patients with acute or chronic complaints following THA and TKA were included. Diagnosis of PJI was established based on the 2018 International Consensus Meeting criteria. A total of 39 patients diagnosed with PJI (32 chronic and seven acute) and 108 patients with aseptic complications were surgically revised.Aims
Methods
For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA. Data from the prospective multicentre Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study were used. Questionnaires were completed preoperatively and six and 12 months postoperatively. Time to RTW was defined as days from surgery until RTW (full or partial). Occupational class was preoperatively assessed and categorized into four categories according to the International Standard Classification of Occupations 2008 (blue-/white-collar, high-/low-skilled). Cox regression analyses were conducted separately for THA and TKA patients. Low-skilled blue-collar work was used as the reference category.Aims
Methods
The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome.Aims
Methods
The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA). Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses.Aims
Methods
The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.Aims
Methods
The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS. From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients’ scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs.Aims
Methods
The primary aim was to assess whether preoperative health-related quality of life (HRQoL) was associated with postoperative mortality following total hip arthroplasty (THA) and knee arthroplasty (KA). Secondary aims were to assess whether patient demographics/comorbidities and/or joint-specific function were associated with postoperative mortality. Patients undergoing THA (n = 717) and KA (n = 742) during a one-year period were identified retrospectively from an arthroplasty register. Patient demographics, comorbidities, Oxford score, and EuroQol five-dimension (EQ-5D) were recorded preoperatively. Patients were followed up for a minimum of seven years and their mortality status was obtained. Cox regression analysis was used to adjust for confounding.Aims
Methods
National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) and the factors associated with its accuracy. We then applied these data to refine estimates of the total national burden of PJI. A total of 561 Australian cases of confirmed PJI were captured by a large, prospective observational study, and matched to data available for the same patients through the AOANJRR.Aims
Methods
Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.Aims
Methods
This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits.Aims
Methods
The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis. Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.Aims
Methods
The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups.Aims
Methods
Elective orthopaedic surgery was cancelled early in the COVID-19 pandemic and is currently running at significantly reduced capacity in most institutions. This has resulted in a significant backlog to treatment, with some hospitals projecting that waiting times for arthroplasty is three times the pre-COVID-19 duration. There is concern that the patient group requiring arthroplasty are often older and have more medical comorbidities—the same group of patients advised they are at higher risk of mortality from catching COVID-19. The aim of this study is to investigate the morbidity and mortality in elective patients operated on during the COVID-19 pandemic and compare this to a pre-pandemic cohort. Primary outcome was 30-day mortality. Secondary outcomes were perioperative complications, including nosocomial COVID-19 infection. These operations were performed in a district general hospital, with COVID-19 acute admissions in the same building. Our institution reinstated elective operations using a “Blue stream” pathway, which involves isolation before and after surgery, COVID-19 testing pre-admission, and separation of ward and theatre pathways for “blue” patients. A register of all arthroplasties was taken, and their clinical course and investigations recorded.Aims
Methods
Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined.Aims
Methods
The aim of this study was to assess the quality of life of patients on the waiting list for a total hip (THA) or knee arthroplasty (KA) during the COVID-19 pandemic. Secondary aims were to assess whether length of time on the waiting list influenced quality of life and rate of deferral of surgery. During the study period (August and September 2020) 843 patients (THA n = 394, KA n = 449) from ten centres in the UK reported their EuroQol five dimension (EQ-5D) scores and completed a waiting list questionnaire (2020 group). Patient demographic details, procedure, and date when listed were recorded. Patients scoring less than zero for their EQ-5D score were defined to be in a health state “worse than death” (WTD). Data from a retrospective cohort (January 2014 to September 2017) were used as the control group.Aims
Methods
In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip. The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression.Aims
Methods
In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties over a three-month period between October and December in 2019, and again in 2020, in the middle of the COVID-19 pandemic. Patient demographics, number of outpatient primary arthroplasty cases, length of stay for admissions, 30-day readmission, and complications were collated.Aims
Methods
To investigate factors that contribute to patient decisions regarding attendance for arthroplasty during the COVID-19 pandemic. A postal questionnaire was distributed to patients on the waiting list for hip or knee arthroplasty in a single tertiary centre within the UK. Patient factors that may have influenced the decision to attend for arthroplasty, global quality of life (QoL) (EuroQol five-dimension three-level (EQ-5D-3L)), and joint-specific QoL (Oxford Hip or Knee Score) were assessed. Patients were asked at which ‘COVID-alert’ level they would be willing to attend an NHS and a “COVID-light” hospital for arthroplasty. Independent predictors were assessed using multivariate logistic regression.Aims
Methods
The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months.Aims
Methods
It can be extremely challenging to determine whether to perform reimplantation in patients who have contradictory serum inflammatory markers and frozen section results. We investigated whether patients with a positive frozen section at reimplantation were at a higher risk of reinfection despite normal ESR and CRP. We retrospectively reviewed 163 consecutive patients with periprosthetic joint infections (PJIs) who had normal ESR and CRP results pre-reimplantation in our hospital from 2014 to 2018. Of these patients, 26 had positive frozen sections at reimplantation. The minimum follow-up time was two years unless reinfection occurred within this period. Univariable and multivariable logistic regression analyses were performed to identify the association between positive frozen sections and treatment failure.Aims
Methods
Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty. We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score.Aims
Methods
Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI. A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies.Aims
Methods
The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons. A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS.Introduction
Methods
Post-operative complications after total hip
or knee replacement can
To assess how the cost-effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) varies with age, sex, and preoperative Oxford Hip or Knee Score (OHS/OKS); and to identify the patient groups for whom THA/TKA is cost-effective. We conducted a cost-effectiveness analysis using a Markov model from a United Kingdom NHS perspective, informed by published analyses of patient-level data. We assessed the cost-effectiveness of THA and TKA in adults with hip or knee osteoarthritis compared with having no arthroplasty surgery during the ten-year time horizon.Aims
Methods
Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs. The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs.Aims
Methods
Infection remains a significant and common complication after joint replacement and there is debate about which contributing factors are important. Few studies have investigated the effect of the operating time on infection. We collected data prospectively from 5277 hip and knee replacements which included the type of procedure, the operating time, the use of drains, the operating theatre, surgeon, age and gender. In a subgroup of 3449 knee replacements further analysis was carried out using the tourniquet time in place of the operating time. These variables were assessed by the use of generalised linear modelling against superficial, deep or joint-space post-operative infection as defined by the Australian Surgical-Site Infection criteria. The overall infection rate was 0.98%. In the replacement data set both male gender (z = 3.097, p = 0.00195) and prolonged operating time (z = 4.325, p <
0.001) were predictive of infection. In the knee subgroup male gender (z = 2.250, p = 0.02447), a longer tourniquet time (z = 2.867, p = 0.00414) and total knee replacement (versus unicompartmental knee replacement) (z = −2.052, p = 0.0420) were predictive of infection. These findings support the view that a prolonged operating time and male gender are associated with an increased incidence of infection. Steps to minimise intra-operative
The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes. A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years (Aims
Patients and Methods
The aims of this study were to determine the indications and
frequency of ordering a CT pulmonary angiography (CTPA) following
primary arthroplasty of the hip and knee, and to determine the number
of positive scans in these patients, the location of emboli and
the outcome for patients undergoing CTPA. We analyzed the use of CTPA, as an inpatient and up to 90 days
as an outpatient, in a cohort of patients and reviewed the medical
records and imaging for each patient undergoing CTPA.Aims
Patients and Methods
Periprosthetic fracture is a significant complication of total
hip and knee arthroplasty. This study aimed to describe the survival
of patients sustaining periprosthetic femoral fractures and compare
this with that of the general population, as well as to identify
the factors that influence survival. A total of 151 patients (women: men 116:35, mean age 74.6 years,
standard deviation 11.5) that sustained a periprosthetic fracture
between January 2005 and October 2012 were retrospectively analysed.
Epidemiological data, comorbidities, type of surgical management,
type of implant, and mortality data were studied.Aims
Patients and Methods
To evaluate the effectiveness of an institutionally developed
algorithm for evaluation and diagnosis of prosthetic joint injection
and to determine the impact of this protocol on overall hospital
re-admissions.p We retrospectively evaluated 2685 total hip arthroplasty (THA)
and total knee arthroplasty (TKA) patients prior to (1263) and following
(1422) the introduction of an infection detection protocol. The
protocol used conservative thresholds for C-reactive protein to
direct the medical attendant to aspirate the joint. The protocol
incorporated a clear set of laboratory and clinical criteria that
allowed a patient to be discharged home if all were met. Patients were
included if they presented to our emergency department within 120
days post-operatively with concerns for swelling, pain or infection
and were excluded if they had an unambiguous infection or if their
chief complaint was non-orthopaedic in nature.Aims
Patients and Methods
To investigate the outcomes of treatment of streptococcal periprosthetic
joint infection (PJI) involving total knee and hip arthroplasties. Streptococcal PJI episodes which occurred between January 2009
and December 2015 were identified from clinical databases. Presentation
and clinical outcomes for 30 streptococcal PJIs in 30 patients (12
hip and 18 knee arthroplasties) following treatment were evaluated
from the medical notes and at review. The Kaplan-Meier survival method
was used to estimate the probability of infection-free survival.
The influence of the biofilm active antibiotic rifampin was also
assessed.Aims
Patients and Methods
The purpose of this current multicentre study is to analyse the
presence of alpha-defensin proteins in synovial fluid using the
Synovasure lateral flow device and to determine its diagnostic reliability
and accuracy compared with the prosthetic joint infection (PJI)
criteria produced by the Musculoskeletal Infection Society (MSIS). A cohort of 121 patients comprising 85 total knee arthroplasties
and 36 total hip arthroplasties was prospectively evaluated between
May 2015 and June 2016 in three different orthopaedic centres. The
tests were performed on patients with a chronically painful prosthesis
undergoing a joint aspiration in a diagnostic pathway or during revision
surgery.Aims
Patients and Methods
Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties. A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group.Objectives
Methods
Valgus knee deformity can present a number of
unique surgical challenges for the total knee arthroplasty (TKA)
surgeon. Understanding the typical patterns of bone and soft-tissue pathology
in the valgus arthritic knee is critical for appropriate surgical
planning. This review aims to provide the knee arthroplasty surgeon
with an understanding of surgical management strategies for the
treatment of valgus knee arthritis. Lateral femoral and tibial deficiencies, contracted lateral soft
tissues, attenuated medial soft tissues, and multiplanar deformities
may all be present in the valgus arthritic knee. A number of classifications
have been reported in order to guide surgical management, and a variety
of surgical strategies have been described with satisfactory clinical
results. Depending on the severity of the deformity, a variety of
TKA implant designs may be appropriate for use. Regardless of an operating surgeon’s preferred surgical strategy,
adherence to a step-wise approach to deformity correction is advised. Cite this article:
The diagnosis of periprosthetic joint infection (PJI) remains
demanding due to limitations of all the available diagnostic tests.
The synovial fluid marker, α-defensin, is a promising adjunct for
the assessment of potential PJI. The purpose of this study was to
investigate the qualitative assessment of α-defensin, using Synovasure
to detect or exclude periprosthetic infection in total joint arthroplasty. We studied 50 patients (28 women, 22 men, mean age 65 years;
20 to 89) with a clinical indication for revision arthroplasty who
met the inclusion criteria of this prospective diagnostic study.
The presence of α-defensin was determined using the qualitative
Synovasure test and compared with standard diagnostic methods for
PJI. Based on modified Musculoskeletal Infection Society (MSIS)
criteria, 13 cases were categorised as septic and 36 as aseptic revisions.
One test was inconclusive.Aims
Patients and Methods
Effective analgesia after total knee arthroplasty (TKA) improves
patient satisfaction, mobility and expedites discharge. This study
assessed whether continuous femoral nerve infusion (CFNI) was superior
to a single-shot femoral nerve block in primary TKA surgery completed
under subarachnoid blockade including morphine. We performed an adequately powered, prospective, randomised,
placebo-controlled trial comparing CFNI of 0.125% bupivacaine Objectives
Methods
Hips with metal-on-metal total hip arthroplasty (MoM THA) have a high rate of adverse local tissue reactions (ALTR), often associated with hypersensitivity reactions. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) measures tissue perfusion with the parameter Ktrans (volume transfer constant of contrast agent). Our purpose was 1) to evaluate the feasibility of DCE-MRI in patients with THA and 2) to compare DCE-MRI in patients with MoM bearings with metal-on-polyethylene (MoP) bearings, hypothesising that the perfusion index Ktrans in hips with MoM THA is higher than in hips with MoP THA. In this pilot study, 16 patients with primary THA were recruited (eight MoM, eight MoP). DCE-MRI of the hip was performed at 1.5 Tesla (T). For each patient, Ktrans was computed voxel-by-voxel in all tissue lateral to the bladder. The mean Ktrans for all voxels was then calculated. These values were compared with respect to implant type and gender, and further correlated with clinical parameters.Objectives
Methods
Since the introduction of the National Institute
for Health and Care Excellence (NICE) guidelines on thromboprophylaxis
and the use of extended thromboprophylaxis with new oral agents,
there have been reports of complications arising as a result of
their use. We have looked at the incidence of wound complications
after the introduction of dabigatran for thromboprophylaxis in our
unit. We investigated the rate of venous thromboembolism and wound
leakage in 1728 patients undergoing primary joint replacement, both
before and after the introduction of dabigatran, and following its
subsequent withdrawal from our unit. We found that the use of dabigatran led to a significant increase
in post-operative wound leakage (20% with dabigatran, 5% with a
multimodal regimen; p <
0.001), which also resulted in an increased
duration of hospital stay. The rate of thromboembolism in patients
receiving dabigatran was higher (1.3%) than in those receiving the multimodal
thromboprophylaxis regimen, including low molecular weight heparin
as an inpatient and the extended use of aspirin (0.3%, p = 0.047).
We have ceased the use of dabigatran for thromboprophylaxis in these
patients. Cite this article:
The aim of our study was to describe the characteristics,
treatment, and outcomes of patients with periprosthetic joint infection
(PJI) and normal inflammatory markers after total knee arthroplasty
(TKA) and total hip arthroplasty (THA). In total 538 TKAs and 414 THAs underwent surgical treatment for
PJI and met the inclusion criteria. Pre-operative erythrocyte sedimentation
rate (ESR) and C-reactive protein level (CRP) were reviewed to identify
the seronegative cohort. An age- and gender-matched cohort was identified
from the remaining patients for comparison. Overall, 4% of confirmed
infections were seronegative (21 TKA and 17 THA). Of those who underwent
pre-operative aspiration, cultures were positive in 76% of TKAs
(n = 13) and 64% of THAs (n = 7). Cell count and differential were
suggestive of infection in 85% of TKA (n = 11) and all THA aspirates
(n = 5). The most common organism was coagulase-negative Cite this article:
The results of hip and knee replacement surgery
are generally regarded as positive for patients. Nonetheless, they are
both major operations and have recognised complications. We present
a review of relevant claims made to the National Health Service
Litigation Authority. Between 1995 and 2010 there were 1004 claims
to a value of £41.5 million following hip replacement surgery and
523 claims to a value of £21 million for knee replacement. The most common
complaint after hip surgery was related to residual neurological
deficit, whereas after knee replacement it was related to infection.
Vascular complications resulted in the highest costs per case in
each group. Although there has been a large increase in the number of operations
performed, there has not been a corresponding relative increase
in litigation. The reasons for litigation have remained largely
unchanged over time after hip replacement. In the case of knee replacement,
although there has been a reduction in claims for infection, there
has been an increase in claims for technical errors. There has also
been a rise in claims for non-specified dissatisfaction. This information
is of value to surgeons and can be used to minimise the potential
mismatch between patient expectation, informed consent and outcome. Cite this article:
Fungal peri-prosthetic infections of the knee
and hip are rare but likely to result in devastating complications.
In this study we evaluated the results of their management using
a single-stage exchange technique. Between 2001 and 2011, 14 patients
(ten hips, four knees) were treated for a peri-prosthetic fungal
infection. One patient was excluded because revision surgery was
not possible owing to a large acetabular defect. One patient developed
a further infection two months post-operatively and was excluded
from the analysis. Two patients died of unrelated causes. After a mean of seven years (3 to 11) a total of ten patients
were available for follow-up. One patient, undergoing revision replacement
of the hip, had a post-operative dislocation. Another patient, undergoing
revision replacement of the knee, developed a wound infection and
required revision 29 months post-operatively following a peri-prosthetic femoral
fracture. The mean Harris hip score increased to 74 points (63 to 84; p
<
0.02) in those undergoing revision replacement of the hip,
and the mean Hospital for Special Surgery knee score increased to
75 points (70 to 80; p <
0.01) in those undergoing revision replacement
of the knee. A single-stage revision following fungal peri-prosthetic infection
is feasible, with an acceptable rate of a satisfactory outcome. Cite this article:
Whether patients with asymptomatic bacteriuria
should be investigated and treated before elective hip and knee replacement
is controversial, although it is a widespread practice. We conducted
a prospective observational cohort study with urine analyses before
surgery and three days post-operatively. Patients with symptomatic
urinary infections or an indwelling catheter were excluded. Post-discharge
surveillance included questionnaires to patients and general practitioners
at three months. Among 510 patients (309 women and 201 men), with
a median age of 69 years (16 to 97) undergoing lower limb joint
replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic
bacteriuria, mostly due to We conclude that testing and treating asymptomatic urinary tract
colonisation before joint replacement is unnecessary. Cite this article:
We reviewed the outcome of 69 uncemented, custom-made,
distal femoral endoprosthetic replacements performed in 69 patients
between 1994 and 2006. There were 31 women and 38 men with a mean
age at implantation of 16.5 years (5 to 37). All procedures were
performed for primary malignant bone tumours of the distal femur.
At a mean follow-up of 124.2 months (4 to 212), 53 patients were
alive, with one patient lost to follow-up. All nine implants (13.0%)
were revised due to aseptic loosening at a mean of 52 months (8
to 91); three implants (4.3%) were revised due to fracture of the
shaft of the prosthesis and three patients (4.3%) had a peri-prosthetic
fracture. Bone remodelling associated with periosteal cortical thinning
adjacent to the uncemented intramedullary stem was seen in 24 patients
but this did not predispose to failure. All aseptically loose implants
in this series were diagnosed to be loose within the first five
years. The results from this study suggest that custom-made uncemented
distal femur replacements have a higher rate of aseptic loosening
compared to published results for this design when used with cemented
fixation. Loosening of uncemented replacements occurs early indicating
that initial fixation of the implant is crucial. Cite this article:
Tranexamic acid is a fibrinolytic inhibitor which reduces blood loss in total knee replacement. We examined the effect on blood loss of a standardised intravenous bolus dose of 1 g of tranexamic acid, given at the induction of anaesthesia in patients undergoing total hip replacement and tested the potential prothrombotic effect by undertaking routine venography. In all, 36 patients received 1 g of tranexamic acid, and 37 no tranexamic acid. Blood loss was measured directly per-operatively and indirectly post-operatively. Tranexamic acid reduced the early post-operative blood loss and total blood loss (p = 0.03 and p = 0.008, respectively) but not the intraoperative blood loss. The tranexamic acid group required fewer transfusions (p = 0.03) and had no increased incidence of deep-vein thrombosis. The reduction in early post-operative blood loss was more marked in women (p = 0.05), in whom this effect was dose-related (r = −0.793). Our study showed that the administration of a standardised pre-operative bolus of 1 g of tranexamic acid was cost-effective in reducing the blood loss and transfusion requirements after total hip replacement, especially in women.
Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use mechanical prophylaxis without anticoagulant drugs. A randomised controlled trial was performed to evaluate whether the incidence of post-operative venous thromboembolism was reduced by using pharmacological anticoagulation with either fondaparinux or enoxaparin in addition to our prophylactic mechanical regimen. A total of 255 Japanese patients who underwent primary unilateral cementless total hip replacement were randomly assigned to one of three postoperative regimens, namely injection of placebo (saline), fondaparinux or enoxaparin. There were 85 patients in each group. All also received the same mechanical prophylaxis during and after the operation, regardless of their assigned group. The primary measurement of efficacy was the presence of a venous thromboembolic event by day 11, defined as deep-vein thrombosis detected by ultrasonography, documented symptomatic deep-vein thrombosis or documented symptomatic pulmonary embolism. The duration of follow-up was 12 weeks. The rate of venous thromboembolism was 7.2% with the placebo, 7.1% with fondaparinux and 6.0% with enoxaparin (p = 0.95 for the comparison of all three groups). Our study confirmed the effectiveness and safety of mechanical thromboprophylaxis without the use of anticoagulant drugs after total hip replacement in Japanese patients.
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis. Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10). Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.
A once-daily dose of rivaroxaban 10 mg, an oral, direct Factor Xa inhibitor, was compared with enoxaparin 40 mg subcutaneously once daily for prevention of venous thromboembolism in three studies of patients undergoing elective hip and knee replacement (RECORD programme). A pooled analysis of data from these studies (n = 9581) showed that rivaroxaban was more effective than enoxaparin in reducing the incidence of the composite of symptomatic venous thromboembolism and all-cause mortality at two weeks (0.4% vs 0.8%, respectively, odds ratio 0.44; 95% confidence interval 0.23 to 0.79; p = 0.005), and at the end of the planned medication period (0.5% vs 1.3%, respectively; odds ratio 0.38; 95% confidence interval 0.22 to 0.62; p <
0.001). The rate of major bleeding was similar at two weeks (0.2% for both) and at the end of the planned medication period (0.3% vs 0.2%). Rivaroxaban started six to eight hours after surgery was more effective than enoxaparin started the previous evening in preventing symptomatic venous thromboembolism and all-cause mortality, without increasing major bleeding.
We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period. The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties.
This prospective study evaluates the role of new laboratory markers in the diagnosis of deep implant infection in 78 patients (41 men and 37 women) with a revision total knee or hip replacement. The mean age at the time of operation was 64.0 years (19 to 90). Intra-operative cultures showed that 21 patients had a septic and 57 an aseptic total joint replacement. The white blood cell count, the erythrocyte sedimentation rate and levels of C-reactive protein, interleukin-6, procalcitonin and tumour necrosis factor (TNF)-α were measured in blood samples before operation. The diagnostic cut-off values were determined by Received Operating Characteristic curve analysis. C-reactive protein (>
3.2 md/dl) and interleukin-6 (>
12 pg/ml) have the highest sensitivity (0.95). Interleukin-6 is less specific than C-reactive protein (0.87 The combination of C-reactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant. A highly specific marker such as procalcitonin and pre-operative aspiration of the joint might be useful in identifying patients with true positive C-reactive protein and/or interleukin-6 levels.
Patients who have undergone total hip or knee replacement (THR and TKR, respectively) are at high risk of venous thromboembolism. We aimed to determine the time courses of both the incidence of venous thromboembolism and effective prophylaxis. Patients with elective primary THR and TKR were enrolled in the multi-national Global Orthopaedic Registry. Data on the incidence of venous thromboembolism and prophylaxis were collected from 6639 THR and 8326 TKR patients. The cumulative incidence of venous thromboembolism within three months of surgery was 1.7% in the THR and 2.3% in the TKR patients. The mean times to venous thromboembolism were 21.5 days ( The risk of venous thromboembolism extends beyond the usual period of hospitalisation, while the duration of prophylaxis is often shorter than this. Practices should be re-assessed to ensure that patients receive appropriate durations of prophylaxis.
We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee. OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements.
