Aims. In-hospital
In Scotland, the number of primary total knee replacements performed annually has been increasing steadily. The price of the implant is fixed but the
Aims. Robotic-assisted total knee arthroplasty (RA-TKA) has been introduced to provide accurate bone cuts and help achieve the target knee alignment, along with symmetric gap balancing. The purpose of this study was to determine if any early clinical benefits could be realized following TKA using robotic-assisted technology. Methods. In all, 140 consecutive patients undergoing RA-TKA and 127 consecutive patients undergoing conventional TKA with minimum six-week follow-up were reviewed. Differences in visual analogue scores (VAS) for pain at rest and with activity, postoperative opiate usage, and
Early and accurate prediction of hospital length-of-stay
(LOS) in patients undergoing knee replacement is important for economic
and operational reasons. Few studies have systematically developed
a multivariable model to predict LOS. We performed a retrospective
cohort study of 1609 patients aged ≥ 50 years who underwent elective,
primary total or unicompartmental knee replacements. Pre-operative
candidate predictors included patient demographics, knee function,
self-reported measures, surgical factors and discharge plans. In
order to develop the model, multivariable regression with bootstrap
internal validation was used. The median LOS for the sample was
four days (interquartile range 4 to 5). Statistically significant
predictors of longer stay included older age, greater number of comorbidities,
less knee flexion range of movement, frequent feelings of being
down and depressed, greater walking aid support required, total
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Aims. The aim of this prospective multicentre study was to describe trends in
Aims. Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. Methods. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl),
Aims. The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and
Aims. The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing
Aims. The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare
Aims. Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods. Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results. Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer
Aims. To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period. Methods. This observational cohort study used electronic health record data from all patients undergoing preoperative screening for primary TKA at a Northern Netherlands hospital between 2009 and 2020. In this timeframe, three perioperative care transitions were divided into four periods: Baseline care (Joint Care, n = 171; May 2009 to August 2010), Function-tailored (n = 404; September 2010 to October 2013), Fast-track (n = 721; November 2013 to May 2018), and Prehabilitation (n = 601; June 2018 to December 2020). In-hospital recovery was measured using inpatient recovery of activities (IROA),
Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute
Aims. Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control,
Aims. To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA. Methods. Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital
Aims. This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA). Methods. Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital
Aims. The primary aim of this study was to compare the knee-specific functional outcome of patellofemoral arthroplasty with total knee arthroplasty (TKA) in the management of patients with patellofemoral osteoarthritis. Patients and Methods. A total of 54 consecutive Avon patellofemoral arthroplasties were identified and propensity-score-matched to a group of 54 patients undergoing a TKA with patellar resurfacing for patellofemoral osteoarthritis. The Oxford Knee Score (OKS), the 12-Item Short-Form Health Survey (SF-12), and patient satisfaction were collected at a mean follow up of 9.2 years (8 to 15). Survival was defined by revision or intention to revise. Results. There was no significant difference in the mean OKS (p > 0.60) or SF-12 scores (p > 0.28) between the groups. There was a lower rate of satisfaction at the final follow-up for the TKA group (78% vs 87%) but this was not statistically significant (odds ratio 0.56, p = 0.21).
Aims. Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. Methods. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and
Aims. Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day
Aims. Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time,
Aims. In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations. Methods. Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by
Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores,
We present detailed information about early morbidity
after aseptic revision knee replacement from a nationwide study.
All aseptic revision knee replacements undertaken between 1st October
2009 and 30th September 2011 were analysed using the Danish National
Patient Registry with additional information from the Danish Knee
Arthroplasty Registry. The 1218 revisions involving 1165 patients
were subdivided into total revisions, large partial revisions, partial
revisions and revisions of unicondylar replacements (UKR revisions).
The mean age was 65.0 years (27 to 94) and the median
Aims. The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018. Methods. We examined our institutional database to identify all Medicare patients who underwent primary TKA from 2017 to 2018. Hospital inpatient or outpatient status was cross-referenced with Centers for Medicare & Medicaid Services (CMS) claims data. Demographics, comorbidities, and outcomes were compared between patients classified as ‘outpatient’ and ‘inpatient’ TKA. Episode-of-care BPCI costs were then compared from 2017 to 2018. Results. Of the 2,135 primary TKA patients in 2018, 908 (43%) were classified as an outpatient and were excluded from BPCI. Inpatient classified patients had longer mean
Aims. The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs). Methods. All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation,
Aims. Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes. Methods. Overall, 40 aseptic full-component RTKA patients were matched (surgical date, age, sex, and body mass index (BMI)) to a group of primary cemented TKA patients. All RTKAs had new uncemented stemmed femoral and tibial components with metaphyseal sleeves. Both groups were treated with an identical postoperative pain protocol. Patients were followed for at least two years. Knee Society Scores (KSS) at six weeks and at final follow-up were recorded for both groups. Results. There was no difference in mean
Introduction. The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and
Aims. The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode. Patients and Methods. Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant. Results. Combined TJA was associated with increased risk of deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty,
Aims. To date, no study has demonstrated an improvement in postoperative outcomes following elective joint arthroplasty with a focus on nutritional intervention for patients with preoperative hypoalbuminaemia. In this prospective study, we evaluated differences in the hospital
Aims. As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of
Aims. 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. Patients and Methods. 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. . Results. A total of 61 patients (85%) were discharged on the same day.
The most common reason for failure was logistical; five patients
had their operation too late in the day. Three patients failed to
mobilise safely, two had inadequate control of pain and one had
a leaking wound. The mean
Aims. Multimodal infiltration of local anaesthetic provides effective
control of pain in patients undergoing total knee arthroplasty (TKA).
There is little information about the added benefits of posterior
capsular infiltration (PCI) using different combinations of local
anaesthetic agents. Our aim was to investigate the effectiveness
of the control of pain using multimodal infiltration with and without
infiltration of the posterior capsule of the knee. Patients and Methods. In a double-blind, randomised controlled trial of patients scheduled
for unilateral primary TKA, 86 were assigned to be treated with
multimodal infiltration with (Group I) or without (Group II) PCI.
Routine associated analgesia included the use of bupivacaine, morphine,
ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled
analgesia (PCA) post-operatively. A visual analogue scale (VAS)
for pain and the use of morphine were recorded 24 hours post-operatively.
Side effects of the infiltration, blood loss, and length of stay
in hospital were recorded. Results. There were no statistically significant differences between the
groups in relation to: VAS pain scores in the first 24 hours post-operatively
(p = 0.693), the use of morphine in the PCA (p = 0.647), blood loss
(p = 0.625), and
Revision total knee arthroplasty (TKA) is a complex
procedure which carries both a greater risk for patients and greater
cost for the treating hospital than does a primary TKA. As well
as the increased cost of peri-operative investigations, blood transfusions,
surgical instrumentation, implants and operating time, there is
a well-documented increased
Aims. The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results. The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the
To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map.Aims
Methods
With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used.Aims
Methods
Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres. mUKAs performed in eight fast-track centres from February 2010 to June 2018 were included from the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Database. All readmissions within 90 days of surgery underwent chart review and readmissions related to the surgical wound or the prosthesis were recorded. Centres were categorized as high-usage centres when using mUKA in ≥ 20% of annual knee arthroplasties. The occurrence of complications between high- and low-usage centres were compared using Fisher’s exact test.Aims
Methods
In a randomised controlled pragmatic trial we
investigated whether local infiltration analgesia would result in earlier
readiness for discharge from hospital after total knee replacement
(TKR) than patient-controlled epidural analgesia (PCEA) plus femoral
nerve block. A total of 45 patients with a mean age of 65 years
(49 to 81) received a local infiltration with a peri-articular injection
of bupivacaine, morphine and methylprednisolone, as well as adjuvant
analgesics. In 45 PCEA+femoral nerve blockade patients with a mean
age of 67 years (50 to 84), analgesia included a bupivacaine nerve
block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics.
The mean time until ready for discharge was 3.2 days (1 to 14) in
the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral
nerve blockade group. The mean pain scores for patients receiving
local infiltration were higher when walking (p = 0.0084), but there
were no statistically significant differences at rest. The mean
opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be
made on the basis of time to discharge after surgery. Most secondary
outcomes were similar, but PCEA+femoral nerve blockade patients
had lower pain scores when walking and during continuous passive
movement. If PCEA+femoral nerve blockade is not readily available, local
infiltration provides similar
Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised. This retrospective, observational study reviewed patients who underwent unilateral, aseptic rTKA at an academic orthopaedic speciality hospital between June 2011 and April 2020 with > one-year of follow-up. Patients were dichotomized based on whether this was their first revision procedure or not. Patient demographics, surgical factors, postoperative outcomes, and re-revision rates were compared between the groups.Aims
Methods
Aims. The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon’s cases and the total time spent in the operating theatre per day. Materials and Methods. A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. Results. A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for
Aims. The pre-operative level of haemoglobin is the strongest predictor
of the peri-operative requirement for blood transfusion after total
knee arthroplasty (TKA). There are, however, no studies reporting
a value that could be considered to be appropriate pre-operatively. . This study aimed to identify threshold pre-operative levels of
haemoglobin that would predict the requirement for blood transfusion
in patients who undergo TKA. . Patients and Methods. Analysis of receiver operator characteristic (ROC) curves of
2284 consecutive patients undergoing unilateral TKA was used to
determine gender specific thresholds predicting peri-operative transfusion
with the highest combined sensitivity and specificity (area under
ROC curve 0.79 for males; 0.78 for females). Results. Threshold levels of 13.75 g/dl for males and 12.75 g/dl for females
were identified. The rates of transfusion in males and females,
respectively above these levels were 3.37% and 7.11%, while below
these levels, they were 16.13% and 28.17%. Pre-operative anaemia
increased the rate of transfusion by 6.38 times in males and 6.27
times in females. Blood transfusion was associated with an increased
incidence of early post-operative confusion (odds ratio (OR) = 3.44),
cardiac arrhythmia (OR = 5.90), urinary catheterisation (OR = 1.60),
the incidence of deep infection (OR = 4.03) and mortality (OR =
2.35) one year post-operatively, and increased
To assess the cost-effectiveness of a two-layer compression bandage versus a standard wool and crepe bandage following total knee arthroplasty, using patient-level data from the Knee Replacement Bandage Study (KReBS). A cost-utility analysis was undertaken alongside KReBS, a pragmatic, two-arm, open label, parallel-group, randomized controlled trial, in terms of the cost per quality-adjusted life year (QALY). Overall, 2,330 participants scheduled for total knee arthroplasty (TKA) were randomized to either a two-layer compression bandage or a standard wool and crepe bandage. Costs were estimated over a 12-month period from the UK NHS perspective, and health outcomes were reported as QALYs based on participants’ EuroQol five-dimesion five-level questionnaire responses. Multiple imputation was used to deal with missing data and sensitivity analyses included a complete case analysis and testing of costing assumptions, with a secondary analysis exploring the inclusion of productivity losses.Aims
Methods
Aims. Adductor canal block (ACB) has emerged as an alternative to femoral nerve block (FNB) for analgesia after total knee arthroplasty (TKA). The optimal duration of maintenance of the ACB is still questionable. The purpose of this study was to compare the analgesic benefits and physiotherapy (PT) outcomes of single-shot ACB to two different regimens of infusion of the continuous ACB, 24-hour and 48-hour infusion. Patients and Methods. This was a prospective, randomized, unblinded study. A total of 159 American Society of Anesthesiologists (ASA) physical status I to III patients scheduled for primary TKA were randomized to one of three study groups. Three patients did not complete the study, leaving 156 patients for final analysis. Group A (n = 53) was the single-shot group (16 female patients and 37 male patients with a mean age of 63.9 years (. sd. 9.6)), group B (n = 51) was the 24-hour infusion group (22 female patients and 29 male patients with a mean age of 66.5 years (. sd. 8.5)), and group C (n = 52) was the 48-hour infusion group (18 female patients and 34 male patients with a mean age of 62.2 years (. sd. 8.7)). Pain scores, opioid requirements, PT test results, and patient-reported outcome instruments were compared between the three groups. Results. The proportion of patients reporting severe pain, defined as a pain score of between 7 and 10, on postoperative day number 2 (POD 2) were 21% for the single-shot group, 14% for the 24-hour block group, and 12% for the 48-hour block group (p = 0.05). Cumulative opioid requirements after 48 hours were similar between the groups. Functional outcomes were similar in all three groups in POD 1 and POD 2. Conclusion. There was no clear benefit of the 24-hour or 48-hour infusions over the single-shot ACB for the primary endpoint of the study. Otherwise, there were marginal benefits for keeping the indwelling catheter for 48 hours in terms of reducing the number of patients with moderate pain and improving the quality of pain management. However, all three groups had similar opioid usage,
This study compared patient-reported outcomes of three total knee arthroplasty (TKA) designs from one manufacturer: one cruciate-retaining (CR) design, and two cruciate-sacrificing designs, anterior-stabilized (AS) and posterior-stabilized (PS). Patients scheduled for primary TKA were included in a single-centre, prospective, three-armed, blinded randomized trial (n = 216; 72 per group). After intraoperative confirmation of posterior cruciate ligament (PCL) integrity, patients were randomly allocated to receive a CR, AS, or PS design from the same TKA system. Insertion of an AS or PS design required PCL resection. The primary outcome was the mean score of all five subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) at two-year follow-up. Secondary outcomes included all KOOS subscales, Oxford Knee Score, EuroQol five-dimension health questionnaire, EuroQol visual analogue scale, range of motion (ROM), and willingness to undergo the operation again. Patient satisfaction was also assessed.Aims
Methods
To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated.Aims
Methods
The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up. This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m2 (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants.Aims
Methods
The use of cementless total knee arthroplasty (TKA) components has increased during the past decade. The initial design of cementless metal-backed patellar components had shown high failure rates due to many factors. The aim of this study was to evaluate the clinical results of a second-generation cementless, metal-backed patellar component of a modern design. This was a retrospective review of 707 primary TKAs in 590 patients from a single institution, using a cementless, metal-backed patellar component with a mean follow-up of 6.9 years (2 to 12). A total of 409 TKAs were performed in 338 females and 298 TKAs in 252 males. The mean age of the patients was 63 years (34 to 87) and their mean BMI was 34.3 kg/m2 (18.8 to 64.5). The patients were chosen to undergo a cementless procedure based on age and preoperative radiological and intraoperative bone quality. Outcome was assessed using the Knee Society knee and function scores and range of motion (ROM), complications, and revisions.Aims
Methods
The clinical results of bilateral total knee replacement staged at a one-week interval during a single hospital admission were compared with bilateral total knee replacements performed under the same anaesthetic and with bilateral total knee replacements performed during two separate admissions. The data were retrospectively reviewed. All operations had been performed by the same surgeon using the same design of prosthesis at a single institution. The operative time and
The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis. This retrospective cohort study used Australian national arthroplasty registry data from January 2013 to January 2021 to identify participants who underwent elective staged BTKA with six to 24 months between procedures. The primary outcome was Oxford Knee Score (OKS) at six months postoperatively for the first TKA compared to the second TKA, adjusted for age and sex. Secondary outcomes compared six-month EuroQol five-dimension five-level (EQ-5D-5L) domain scores, EQ-5D index scores, and the EQ visual analogue scale (EQ-VAS) between knees at six months postoperatively.Aims
Methods
In this study we randomised 140 patients who
were due to undergo primary total knee arthroplasty (TKA) to have the
procedure performed using either patient-specific cutting guides
(PSCG) or conventional instrumentation (CI). . The primary outcome measure was the mechanical axis, as measured
at three months on a standing long-leg radiograph by the hip–knee–ankle
(HKA) angle. This was undertaken by an independent observer who
was blinded to the instrumentation. Secondary outcome measures were
component positioning, operating time, Knee Society and Oxford knee
scores, blood loss and
Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m2). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m2 to examine whether this is supported. This single-centre study compared 169 consecutive patients with severe obesity (BMI ≥ 40 kg/m2) (mean age 65.2 years (40 to 87); mean BMI 44.2 kg/m2 (40 to 66); 129/169 female) undergoing unilateral TKA to a propensity score matched (age, sex, preoperative Oxford Knee Score (OKS)) cohort with a BMI < 40 kg/m2 in a 1:1 ratio. Demographic data, comorbidities, and complications to one year were recorded. Preoperative and one-year patient-reported outcome measures (PROMs) were completed: EuroQol five-dimension three-level questionnaire (EQ-5D-3L), OKS, pain, and satisfaction. Using national life expectancy data with obesity correction and the 2020 NHS National Tariff, QALYs (discounted at 3.5%), and direct medical costs accrued over a patient’s lifetime, were calculated. Probabilistic sensitivity analysis (PSA) was used to model variation in cost/QALY for each cohort across 1,000 simulations.Aims
Methods
Unicompartmental knee arthroplasty (UKA) is the preferred treatment for anterior medial knee osteoarthritis (OA) owing to the rapid postoperative recovery. However, the risk factors for UKA failure remain controversial. The clinical data of Oxford mobile-bearing UKAs performed between 2011 and 2017 with a minimum follow-up of five years were retrospectively analyzed. Demographic, surgical, and follow-up data were collected. The Cox proportional hazards model was used to identify the risk factors that contribute to UKA failure. Kaplan-Meier survival was used to compare the effect of the prosthesis position on UKA survival.Aims
Methods
This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults. This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded.Aims
Methods
The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA. A randomized controlled trial was undertaken, and patients were randomized to either mTKA or rTKA. The primary objective was functional improvement at six months. Overall, 100 patients were randomized, 50 to each group, of whom 46 rTKA and 41 mTKA patients were available for review at six months following surgery. There were no differences between the two groups.Aims
Methods
Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain.Aims
Methods
Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.Aims
Methods
We prospectively followed 171 patients who underwent
bilateral unicompartmental knee replacement (UKR) over a period
of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral
procedure and 47 (27.5%) underwent a staged procedure. The mean
cumulative operating time and
Many patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA. The prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA.Aims
Methods
It has previously been shown that higher-volume hospitals have better outcomes following revision total knee arthroplasty (rTKA). We were unable to identify any studies which investigated the effect of surgeon volume on the outcome of rTKA. We sought to investigate whether patients of high-volume (HV) rTKA surgeons have better outcomes following this procedure compared with those of low-volume (LV) surgeons. This retrospective study involved patients who underwent aseptic unilateral rTKA between January 2016 and March 2019, using the database of a large urban academic medical centre. Surgeons who performed ≥ 19 aseptic rTKAs per year during the study period were considered HV and those who performed < 19 per year were considered LV. Demographic characteristics, surgical factors, and postoperative outcomes were compared between the two groups.Aims
Methods
We have carried out a randomised, controlled trial on 70 patients having unilateral total knee replacement in which transfusion was either with homologous bank blood or by reinfusion of unwashed blood salvaged after operation. No complications or adverse effects were observed from reinfusion. The need for bank blood was reduced by 86% in the reinfusion group but, more importantly, the number of infective episodes was significantly less when the use of bank blood was avoided. The mean
Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA). This was a retrospective cohort study of 60 consecutive unilateral (PDFFs) of Su types II (40/60) and III (20/60) in patients aged ≥ 60 years: 33 underwent LLP-ORIF (mean age 81.3 years (SD 10.5), BMI 26.7 (SD 5.5); 29/33 female); and 27 underwent DFA (mean age 78.8 years (SD 8.3); BMI 26.7 (SD 6.6); 19/27 female). The primary outcome measure was reoperation. Secondary outcomes included perioperative complications, calculated blood loss, transfusion requirements, functional mobility status, length of acute hospital stay, discharge destination and mortality. Kaplan-Meier survival analysis was performed. Cox multivariate regression analysis was performed to identify risk factors for reoperation after LLP-ORIF.Aims
Methods
The aim of this study is to compare the effectiveness and safety of thromboprophylactic treatments in patients undergoing primary total knee arthroplasty (TKA). Using nationwide medical registries, we identified patients with a primary TKA performed in Denmark between 1 January 2013 and 31 December 2018 who received thromboprophylactic treatment. We examined the 90-day risk of venous thromboembolism (VTE), major bleeding, and all-cause mortality following surgery. We used a Cox regression model to compute hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome, pairwise comparing treatment with dalteparin or dabigatran with rivaroxaban as the reference. The HRs were both computed using a multivariable and a propensity score matched analysis.Aims
Methods
To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort.Aims
Methods
The aim of this study was to compare the clinical outcomes of robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) during the first six weeks and at one year postoperatively. A per protocol analysis of 76 patients, 43 of whom underwent TKA and 34 of whom underwent bi-UKA, was performed from a prospective, single-centre, randomized controlled trial. Diaries kept by the patients recorded pain, function, and the use of analgesics daily throughout the first week and weekly between the second and sixth weeks. Patient-reported outcome measures (PROMs) were compared preoperatively, and at three months and one year postoperatively. Data were also compared longitudinally and a subgroup analysis was conducted, stratified by preoperative PROM status.Aims
Methods
It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes.Aims
Methods
Medial pivot (MP) total knee arthroplasties (TKAs) were designed to mimic native knee kinematics with their deep medial congruent fitting of the tibia to the femur almost like a ball-on-socket, and a flat lateral part. GMK Sphere is a novel MP implant. Our primary aim was to study the migration pattern of the tibial tray of this TKA. A total of 31 patients were recruited to this single-group radiostereometric analysis (RSA) study and received a medial pivot GMK Sphere TKA. The distributions of male patients versus female patients and right versus left knees were 21:10 and 17:14, respectively. Mean BMI was 29 kg/m2 (95% confidence interval (CI) 27 to 30) and mean age at surgery was 63 years (95% CI 61 to 66). Maximum total point motions (MTPMs), medial, proximal, and anterior translations and transversal, internal, and varus rotations were calculated at three, 12, and 24 months. Patient-reported outcome measure data were also retrieved.Aims
Methods
The postoperative analgesic effects of intra-articular injections of bupivacaine and/or morphine were examined prospectively in 437 patients who had total knee replacement for osteoarthritis. They were divided randomly into four groups. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II received 10 ml of bupivacaine (2.5 mg/ml), group III received 10 ml of saline, and group IV received 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). All analgesics administered in the first 24 hours after operation were recorded. The patients rated their pain on the McGill-Melzack scale at 1, 6, 12 and 24 hours. No significant differences were found between any of the groups in the use of Demoral and/or Toradol in 24 hours, the
In total knee arthroplasty (TKA), blood loss continues internally after surgery is complete. Typically, the total loss over 48 postoperative hours can be around 1,300 ml, with most occurring within the first 24 hours. We hypothesize that the full potential of tranexamic acid (TXA) to decrease TKA blood loss has not yet been harnessed because it is rarely used beyond the intraoperative period, and is usually withheld from ‘high-risk’ patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease, a patient group who would benefit greatly from a reduced blood loss. TRAC-24 was a prospective, phase IV, single-centre, open label, parallel group, randomized controlled trial on patients undergoing TKA, including those labelled as high-risk. The primary outcome was indirect calculated blood loss (IBL) at 48 hours. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional 24-hour postoperative oral regime of four 1 g doses, while Group 2 only received the intraoperative dose and Group 3 did not receive any TXA.Aims
Methods
The purpose of this study was to develop a personalized outcome prediction tool, to be used with knee arthroplasty patients, that predicts outcomes (lengths of stay (LOS), 90 day readmission, and one-year patient-reported outcome measures (PROMs) on an individual basis and allows for dynamic modifiable risk factors. Data were prospectively collected on all patients who underwent total or unicompartmental knee arthroplasty at a between July 2015 and June 2018. Cohort 1 (n = 5,958) was utilized to develop models for LOS and 90 day readmission. Cohort 2 (n = 2,391, surgery date 2015 to 2017) was utilized to develop models for one-year improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, KOOS function score, and KOOS quality of life (QOL) score. Model accuracies within the imputed data set were assessed through cross-validation with root mean square errors (RMSEs) and mean absolute errors (MAEs) for the LOS and PROMs models, and the index of prediction accuracy (IPA), and area under the curve (AUC) for the readmission models. Model accuracies in new patient data sets were assessed with AUC.Aims
Methods
There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service. Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020.Aims
Methods
Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system.Aims
Methods
Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes. Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty. This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice. Cite this article:
The aim is to assess the cost-effectiveness of patellofemoral arthroplasty (PFA) in comparison with total knee arthroplasty (TKA) for the treatment of isolated patellofemoral osteoarthritis (OA) based on prospectively collected data on health outcomes and resource use from a blinded, randomized, clinical trial. A total of 100 patients with isolated patellofemoral osteoarthritis were randomized to receive either PFA or TKA by experienced knee surgeons trained in using both implants. Patients completed patient-reported outcomes including EuroQol five-dimension questionnaire (EQ-5D) and 6-Item Short-Form Health Survey questionnaire (SF-6D) before the procedure. The scores were completed again after six weeks, three, six, and nine months, and again after one- and two-year post-surgery and yearly henceforth. Time-weighted outcome measures were constructed. Cost data were obtained from clinical registrations and patient-reported questionnaires. Incremental gain in health outcomes (quality-adjusted life-years (QALYs)) and incremental costs were compared for the two groups of patients. Net monetary benefit was calculated assuming a threshold value of €10,000, €35,000, and €50,000 per QALY and used to test the statistical uncertainty and central assumptions about outcomes and costs.Aims
Methods
The aim of this study was to assess the effectiveness of perioperative essential amino acid (EAA) supplementation to prevent rectus femoris muscle atrophy and facilitate early recovery of function after total knee arthroplasty (TKA). The study involved 60 patients who underwent unilateral TKA for primary knee osteo-arthritis (OA). This was a double-blind, placebo-controlled, randomized control trial with patients randomly allocated to two groups, 30 patients each: the essential amino acid supplementation (9 g daily) and placebo (lactose powder, 9 g daily) groups. Supplementation and placebo were provided from one week before to two weeks after surgery. The area of the rectus femoris muscle were measured by ultrasound imaging one month before surgery and one, two, three, and four weeks postoperatively. The serum albumin level, a visual analogue knee pain score, and mobility were also measured at each time point. The time to recovery of activities of daily living (ADLs) was recorded. Postoperative nutrition and physiotherapy were identical in both groups.Aims
Methods
To evaluate the influence of discharge timing on 30-day complications following total knee arthroplasty (TKA). We identified patients aged 18 years or older who underwent TKA between 2005 and 2016 from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database. We propensity score-matched length-of-stay (LOS) groups using all relevant covariables. We used multivariable regression to determine if the rate of complications and re-admissions differed depending on LOS.Aims
Patients and Methods
Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. From six-centres, 233 revision TKAs were randomized to one of four regimens: 1 g of intravenous (IV) TXA given prior to the skin incision, a double-dose regimen of 1 g IV TXA given both prior to skin incision and at time of wound closure, a combination of 1 g IV TXA given prior to skin incision and 1 g of intraoperative topical TXA, or three doses of 1950 mg oral TXA given two hours preoperatively, six hours postoperatively, and on the morning of postoperative day one. Randomization was performed based on the type of revision procedure to ensure equivalent distribution among groups. Power analysis determined that 40 patients per group were necessary to identify a 1 g/dl difference in the reduction of haemoglobin postoperatively between groups with an alpha of 0.05 and power of 0.80. Per-protocol analysis involved regression analysis and two one-sided Aims
Patients and Methods
The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly. This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden’s index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications.Aims
Patients and Methods
Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) Aims
Materials and Methods
The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA). In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform.Aims
Patients and Methods
The Bundled Payments for Care Improvement (BPCI) initiative has identified pathways for improving the value of care. However, patient-specific modifiable and non-modifiable risk factors may increase costs beyond the target payment. We sought to identify risk factors for exceeding our institution’s target payment, the so-called ‘bundle busters’. Using our data warehouse and Centers for Medicare and Medicaid Services (CMS) data we identified all 412 patients who underwent total joint arthroplasty and qualified for our institution’s BPCI model, between July 2015 and May 2017. Episodes where CMS payments exceeded the target payment were considered ‘busters’ (n = 123). Risk ratios (RRs) were calculated using a modified Poisson regression analysis.Aims
Patients and Methods
Unicompartmental knee arthroplasty (UKA) provides improved early functional outcomes and less postoperative morbidity and pain compared with total knee arthroplasty (TKA). Opioid prescribing has increased in the last two decades, and recently states in the USA have developed online Prescription Drug Monitoring Programs to prevent overprescribing of controlled substances. This study evaluates differences in opioid requirements between patients undergoing TKA and UKA. We retrospectively reviewed 676 consecutive TKAs and 241 UKAs. Opioid prescriptions in morphine milligram equivalents (MMEs), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring websites six months before and nine months after the initial procedures. Bivariate and multivariate analysis were performed for patients who had a second prescription and continued use.Aims
Patients and Methods
With an ageing population of patients who are infected with hepatitis C virus (HCV), the demand for total knee arthroplasty (TKA) in this high-risk group continues to grow. It has previously been shown that HCV infection predisposes to poor outcomes following TKA. However, there is little information about the outcome of TKA in patients with HCV who have been treated successfully. The purpose of this study was to compare the outcomes of TKA in untreated HCV patients and those with HCV who have been successfully treated and have a serologically confirmed remission. A retrospective review of all patients diagnosed with HCV who underwent primary TKA between November 2011 and April 2018 was conducted. HCV patients were divided into two groups: 1) those whose HCV was cured (HCV-C); and 2) those in whom it was untreated (HCV-UT). All variables including demographics, HCV infection characteristics, surgical details, and postoperative medical and surgical outcomes were evaluated. There were 64 patients (70 TKAs) in the HCV-C group and 63 patients (71 TKAs) in the HCV-UT cohort. The mean age at the time of surgery was 63.0 years (Aims
Patients and Methods
Our intention was to investigate if the highly porous biological fixation surfaces of a new 3D-printed total knee arthroplasty (TKA) achieved adequate fixation of the tibial and patellar components to the underlying bone. A total of 29 patients undergoing primary TKA consented to participate in this prospective cohort study. All patients received a highly porous tibial baseplate and metal-backed patella. Patient-reported outcomes measures were recorded and implant migration was assessed using radiostereometric analysis.Aims
Patients and Methods
The aim of this study was to identify the most effective regimen
of multiple doses of oral tranexamic acid (TXA) in achieving maximum
reduction of blood loss in total knee arthroplasty (TKA). In this randomized controlled trial, 200 patients were randomized
to receive a single dose of 2.0 g of TXA orally two hours preoperatively
(group A), a single dose of TXA followed by 1.0 g orally three hours
postoperatively (group B), a single dose of TXA followed by 1.0 g
three and nine hours postoperatively (group C), or a single dose
of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively
(group D). All patients followed a routine enhanced-recovery protocol.
The primary outcome measure was the total blood loss. Secondary
outcome measures were hidden blood loss (HBL), reduction in the
level of haemoglobin, the rate of transfusion and adverse events.Aims
Patients and Methods
The objective of this study was to compare early postoperative
functional outcomes and time to hospital discharge between conventional
jig-based total knee arthroplasty (TKA) and robotic-arm assisted
TKA. This prospective cohort study included 40 consecutive patients
undergoing conventional jig-based TKA followed by 40 consecutive
patients receiving robotic-arm assisted TKA. All surgical procedures
were performed by a single surgeon using the medial parapatellar
approach with identical implant designs and standardized postoperative inpatient
rehabilitation. Inpatient functional outcomes and time to hospital
discharge were collected in all study patients.Aims
Patients and Methods
This non-blinded randomised controlled trial compared the effect
of patient-controlled epidural analgesia (PCEA) A total of 242 patients were randomised; 20 were excluded due
to failure of spinal anaesthesia leaving 109 patients in the PCEA
group and 113 in the LIA group. Patients were reviewed at six weeks
and one year post-operatively.Aims
Patients and Methods
The aims of this study were to compare the efficacy of two agents,
aspirin and warfarin, for the prevention of venous thromboembolism
(VTE) after simultaneous bilateral total knee arthroplasty (SBTKA),
and to elucidate the risk of VTE conferred by this procedure compared
with unilateral TKA (UTKA). A retrospective, multi-institutional study was conducted on 18
951 patients, 3685 who underwent SBTKA and 15 266 who underwent
UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient
was assigned an individualised baseline VTE risk score based on
a system using the Nationwide Inpatient Sample. Symptomatic VTE,
including pulmonary embolism (PE) and deep vein thrombosis (DVT),
were identified in the first 90 days post-operatively. Statistical
analyses were performed with logistic regression accounting for
baseline VTE risk.Aims
Patients and Methods
Tranexamic acid (TXA) is an antifibrinolytic agent used as a blood-sparing technique in total knee arthroplasty (TKA), and is routinely administered by intravenous (IV) or intra-articular (IA) injection. Recently, a novel method of TXA administration, the combined IV and IA application of TXA, has been applied in TKA. However, the scientific evidence of combined administration of TXA in TKA is still meagre. This meta-analysis aimed to investigate the efficacy and safety of combined IV and IA TXA in patients undergoing TKA. A systematic search was carried out in PubMed, the Cochrane Clinical Trial Register (Issue12 2015), Embase, Web of Science and the Chinese Biomedical Database. Only randomised controlled trials (RCT) evaluating the efficacy and safety of combined use TXA in TKA were identified. Two authors independently identified the eligible studies, extracted data and assessed the methodological quality of included studies. Meta-analysis was conducted using Review Manager 5.3 software.Objectives
Materials and Methods
This study investigated the influence of body mass index (BMI)
on the post-operative fall in the level of haemoglobin (Hb), length
of hospital stay (LOS), 30-day re-admission rate, functional outcome
and quality of life, two years after total knee arthroplasty (TKA). A total of 7733 patients who underwent unilateral primary TKA
between 2001 and 2010 were included. The mean age was 67 years (30
to 90). There were 1421 males and 6312 females. The patients were
categorised into three groups: BMI <
25.0 kg/m2 (normal);
BMI between 25.0 and 39.9 kg/m2 (obese); and BMI ≥ 40.0
kg/m2 (morbidly obese).Aims
Patients and Methods
Since redesign of the Oxford phase III mobile-bearing unicompartmental
knee arthroplasty (UKA) femoral component to a twin-peg design,
there has not been a direct comparison to total knee arthroplasty
(TKA). Thus, we explored differences between the two cohorts. A total of 168 patients (201 knees) underwent medial UKA with
the Oxford Partial Knee Twin-Peg. These patients were compared with
a randomly selected group of 177 patients (189 knees) with primary
Vanguard TKA. Patient demographics, Knee Society (KS) scores and
range of movement (ROM) were compared between the two cohorts. Additionally,
revision, re-operation and manipulation under anaesthesia rates
were analysed.Aims
Patients and Methods
Our aim was to examine the clinical and radiographic outcomes
in 257 consecutive Oxford unicompartmental knee arthroplasties (OUKAs)
(238 patients), five years post-operatively. A retrospective evaluation was undertaken of patients treated
between April 2008 and October 2010 in a regional centre by two
non-designing surgeons with no previous experience of UKAs. The
Oxford Knee Scores (OKSs) were recorded and fluoroscopically aligned
radiographs were assessed post-operatively at one and five years.Aims
Patients and Methods
To investigate whether pre-operative functional mobility is a
determinant of delayed inpatient recovery of activities (IRoA) after
total knee arthroplasty (TKA) in three periods that coincided with
changes in the clinical pathway. All patients (n = 682, 73% women, mean age 70 years, standard
deviation 9) scheduled for TKA between 2009 and 2015 were pre-operatively
screened for functional mobility by the Timed-up-and-Go test (TUG)
and De Morton mobility index (DEMMI). The cut-off point for delayed
IRoA was set on the day that 70% of the patients were recovered,
according to the Modified Iowa Levels of Assistance Scale (mILAS)
(a 5-item activity scale). In a multivariable logistic regression
analysis, we added either the TUG or the DEMMI to a reference model
including established determinants.Aims
Patients and Methods
We have previously reported the short-term radiological
results of a randomised controlled trial comparing kinematically
aligned total knee replacement (TKR) and mechanically aligned TKR,
along with early pain and function scores. In this study we report
the two-year clinical results from this trial. A total of 88 patients
(88 knees) were randomly allocated to undergo either kinematically
aligned TKR using patient-specific guides, or mechanically aligned
TKR using conventional instruments. They were analysed on an intention-to-treat
basis. The patients and the clinical evaluator were blinded to the
method of alignment. At a minimum of two years, all outcomes were better for the kinematically
aligned group, as determined by the mean Oxford knee score (40 (15
to 48) In this study, the use of a kinematic alignment technique performed
with patient-specific guides provided better pain relief and restored
better function and range of movement than the mechanical alignment
technique performed with conventional instruments. Cite this article:
Patient specific instrumentation (PSI) uses advanced
imaging of the knee (CT or MRI) to generate individualised cutting
blocks aimed to make the procedure of total knee arthroplasty (TKA)
more accurate and efficient. However, in this era of healthcare
cost consciousness, the value of new technologies needs to be critically
evaluated. There have been several comparative studies looking at
PSI Cite this article:
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)
There is a large amount of evidence available
about the relative merits of unicompartmental and total knee arthroplasty
(UKA and TKA). Based on the same evidence, different people draw
different conclusions and as a result, there is great variability
in the usage of UKA. The revision rate of UKA is much higher than TKA and so some
surgeons conclude that UKA should not be performed. Other surgeons
believe that the main reason for the high revision rate is that
UKA is easy to revise and, therefore, the threshold for revision
is low. They also believe that UKA has many advantages over TKA
such as a faster recovery, lower morbidity and mortality and better
function. They therefore conclude that UKA should be undertaken
whenever appropriate. The solution to this argument is to minimise the revision rate
of UKA, thereby addressing the main disadvantage of UKA. The evidence
suggests that this will be achieved if surgeons use UKA for at least
20% of their knee arthroplasties and use implants that are appropriate
for these broad indications. Cite this article:
Controversy remains regarding the optimal post-operative
analgesic regimen following total knee replacement. A delicate balance
is required between the provision of adequate pain relief and early
mobilisation. By reviewing 29 randomised trials we sought to establish
whether local infiltration of analgesia directly into the knee during
surgery provides better pain relief and a more rapid rehabilitation.
Although we were able to conclude that local infiltration can provide
improved post-operative pain relief, and to suggest the most promising
technique of administration, there is no evidence that it reduces
hospital stay.
We assessed the effect of social deprivation
upon the Oxford knee score (OKS), the Short-Form 12 (SF-12) and patient
satisfaction after total knee replacement (TKR). An analysis of
966 patients undergoing primary TKR for symptomatic osteoarthritis
(OA) was performed. Social deprivation was assessed using the Scottish
Index of Multiple Deprivation. Those patients that were most deprived
underwent surgery at an earlier age (p = 0.018), were more likely
to be female (p = 0.046), to endure more comorbidities (p = 0.04)
and to suffer worse pain and function according to the OKS (p <
0.001). In addition, deprivation was also associated with poor mental
health (p = 0.002), which was assessed using the mental component
(MCS) of the SF-12 score. Multivariable analysis was used to identify
independent predictors of outcome at one year. Pre-operative OKS,
SF-12 MCS, back pain, and four or more comorbidities were independent
predictors of improvement in the OKS (all p <
0.001). Pre-operative
OKS and improvement in the OKS were independent predictors of dissatisfaction
(p = 0.003 and p <
0.001, respectively). Although improvement
in the OKS and dissatisfaction after TKR were not significantly
associated with social deprivation Cite this article:
Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p <
0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement.
We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood. Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.