Aims. The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing
Aims. To develop and validate patient-centred algorithms that estimate individual risk of death over the first year after elective joint arthroplasty surgery for osteoarthritis. Methods. A total of 763,213 hip and knee
Data of high quality are critical for the meaningful interpretation of registry information. The National Joint Registry (NJR) was established in 2002 as the result of an unexpectedly high failure rate of a cemented total hip arthroplasty. The NJR began data collection in 2003. In this study we report on the outcomes following the establishment of a formal data quality (DQ) audit process within the NJR, within which each patient episode entry is validated against the hospital unit’s Patient Administration System and vice-versa. This process enables bidirectional validation of every NJR entry and retrospective correction of any errors in the dataset. In 2014/15 baseline average compliance was 92.6% and this increased year-on-year with repeated audit cycles to 96.0% in 2018/19, with 76.4% of units achieving > 95% compliance. Following the closure of the audit cycle, an overall compliance rate of 97.9% was achieved for the 2018/19 period. An automated system was initiated in 2018 to reduce administrative burden and to integrate the DQ process into standard workflows. Our processes and quality improvement results demonstrate that DQ may be implemented successfully at national level, while minimizing the burden on hospitals. Cite this article:
Aims. 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. Methods. 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
Aims. The COVID-19 pandemic has disrupted the provision of
Aims. The surgical helmet system (SHS) was developed to reduce the risk of periprosthetic joint infection (PJI), but the evidence is contradictory, with some studies suggesting an increased risk of PJI due to potential leakage through the glove-gown interface (GGI) caused by its positive pressure. We assumed that SHS and glove exchange had an impact on the leakage via GGI. Methods. There were 404
Aims. Day-case
Aims. National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National
Aims. Total joint replacement (TJR) is a high-cost, high-volume procedure that impacts patients’ quality of life. Informed decisions are important for patients facing TJR. The quality of information provided by websites regarding TJR is highly variable. We aimed to measure the quality of TJR information online. Methods. We identified 10,800 websites using 18 TJR-related keywords (conditions and procedures) across the Australian, French, German and Spanish Google search engines. We used the Health on the Net (HON) toolbar to evaluate the first 150 websites downloaded for every keyword in each language. The quality of information on websites was inspected, accounting for differences by language and tertiles. We also undertook an analysis of English websites to explore types of website providers. Results. ‘Total
Total knee arthroplasty (TKR) using a medial capsular approach gives worse results in arthritic knees with valgus deformity than in those in varus, usually because of swelling, poor wound healing and stiffness, instability, recurrent valgus deformity and poor patellar tracking. A technique for
Introduction. The enhanced recovery after surgery (ERAS) concept in
The aim of this study was to assess the effect of multimorbidity
on improvements in health-related quality of life (HRQoL) following
total hip arthroplasty (THA) and total knee arthroplasty (TKA). Using data from a regional joint registry for 14 573 patients,
HRQoL was measured prior and one year following surgery using the
Oxford Hip Score (OHS) and Oxford Knee Score (OKS), and the 12-Item
Short-Form Health Survey Physical and Mental Component Summary scores
(PCS and MCS, respectively). Multimorbidity was defined as the concurrence
of two or more self-reported chronic conditions. A linear mixed-effects
model was used to test the effects of multimorbidity and the number
of chronic conditions on improvements in HRQoL.Aims
Patients and Methods
Aims. 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. Patients and Methods. A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years (. sd. 11.6; 14 to 95); mean body mass index (BMI) 28.5 kg/m. 2. (. sd. 5.7; 15 to 72); 1253 female (60%)) and 2168 patients undergoing 2168 TKAs (mean age 69.3 years (. sd. 9.6; 22 to 91); BMI 30.8 kg/m. 2. (. sd. 5.8; 13 to 57); 1244 female (57%)) were recorded. Univariate analysis was used to identify variables associated with an EQ-5D score < 0: age, BMI, sex, deprivation quintile, comorbidities, and joint-specific function measured using the Oxford Hip Score (OHS) or Oxford Knee Score (OKS). Multivariate logistic regression was performed. EQ-5D and OHS/OKS were repeated one year following surgery in 1555 THAs and 1700 TKAs. Results. Preoperatively, 391 THA patients (19%) and 263 TKA patients (12%) were WTD. Multivariate analysis identified preoperative OHS, deprivation, and chronic obstructive pulmonary disease in THA, and OKS, peripheral arterial disease, and inflammatory arthropathy in TKA as independently associated with WTD status (p < 0.05). One year following
Aims. While preoperative bloodwork is routinely ordered, its value in determining which patients are at risk of postoperative readmission following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is unclear. The objective of this study was to determine which routinely ordered preoperative blood markers have the strongest association with acute hospital readmission for patients undergoing elective TKA and THA. Methods. Two population-based retrospective cohorts were assembled for all adult primary elective TKA (n = 137,969) and THA (n = 78,532) patients between 2011 to 2018 across 678 North American hospitals using the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) registry. Six routinely ordered preoperative blood markers - albumin, haematocrit, platelet count, white blood cell count (WBC), estimated glomerular filtration rate (eGFR), and sodium level - were queried. The association between preoperative blood marker values and all-cause readmission within 30 days of surgery was compared using univariable analysis and multivariable logistic regression adjusted for relevant patient and treatment factors. Results. The mean TKA age was 66.6 years (SD 9.6) with 62% being females (n = 85,163/137,969), while in the THA cohort the mean age was 64.7 years (SD 11.4) with 54% being female (n = 42,637/78,532). In both cohorts, preoperative hypoalbuminemia (< 35 g/l) was associated with a 1.5- and 1.8-times increased odds of 30-day readmission following TKA and THA, respectively. In TKA patients, decreased eGFR demonstrated the strongest association with acute readmission with a standardized odds ratio of 0.75 per two standard deviations increase (p < 0.0001). Conclusion. In this population level cohort analysis of
Despite numerous studies focusing on periprosthetic joint infections (PJIs), there are no robust data on the risk factors and timing of metachronous infections. Metachronous PJIs are PJIs that can arise in the same or other artificial joints after a period of time, in patients who have previously had PJI. Between January 2010 and December 2018, 661 patients with multiple joint prostheses in situ were treated for PJI at our institution. Of these, 73 patients (11%) developed a metachronous PJI (periprosthetic infection in patients who have previously had PJI in another joint, after a lag period) after a mean time interval of 49.5 months (SD 30.24; 7 to 82.9). To identify patient-related risk factors for a metachronous PJI, the following parameters were analyzed: sex; age; BMI; and pre-existing comorbidity. Metachronous infections were divided into three groups: Group 1, metachronous infections in ipsilateral joints; Group 2, metachronous infections of the contralateral lower limb; and Group 3, metachronous infections of the lower and upper limb.Aims
Methods
To investigate whether elective joint arthroplasty performed
at the weekend is associated with a different 30-day mortality We examined the 30-day cumulative mortality rate (Kaplan-Meier)
for all elective hip and knee arthroplasties performed in England
and Wales between 1st April 2003 and 31st December 2014, comprising
118 096 episodes undertaken at the weekend and 1 233 882 episodes
performed on a weekday. We used Cox proportional-hazards regression
models to assess for time-dependent variation and adjusted for identified
risk factors for mortality.Aims
Patients and Methods
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
Our aim was to determine the pre-operative sporting profiles of patients undergoing primary
The aim of this study was to define return to
theatre (RTT) rates for elective hip and knee replacement (HR and
KR), to describe the predictors and to show the variations in risk-adjusted
rates by surgical team and hospital using national English hospital
administrative data. . We examined information on 260 206 HRs and 315 249 KRs undertaken
between April 2007 and March 2012. The 90-day RTT rates were 2.1%
for HR and 1.8% for KR. Male gender, obesity, diabetes and several
other comorbidities were associated with higher odds for both index
procedures. For HR, hip resurfacing had half the odds of cement fixation
(OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR,
unicondylar KR had half the odds of total
We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist
Using general practitioner records and hospital
notes and through direct telephone conversation with patients, we investigated
the accuracy of nine patient-reported complications gathered from
a self-completed questionnaire after elective joint replacement
surgery of the hip and knee. A total of 402 post-discharge complications
were reported after 8546 elective operations that were undertaken
within a three-year period. These were reported by 136 men and 240
women with a mean age of 71.8 years (34 to 93). A total of 319 reported
complications (79.4%; 95% confidence interval 75.4 to 83.3) were
confirmed to be correct. High rates of correct reporting were demonstrated
for infection (94.5%) and the need for further surgery (100%), whereas
the rates of reporting deep-vein thrombosis (DVT), pulmonary embolism,
myocardial infarction and stroke were lower (75% to 84.2%). Dislocation,
peri-prosthetic fractures and nerve palsy had modest rates of correct
reporting (36% to 57.1%). More patients who had knee surgery delivered
incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations, it appears that post-operative complications
may form part of a larger patient-reported outcome programme after
elective
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
The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better.Aims
Methods
The aim of this study was to determine if a change
in antibiotic prophylaxis for routine hip and knee replacement was
associated with an increased risk of acute renal impairment. . We identified 238 patients (128 knees and 110 hips) who had received
a single prophylactic dose of 1.5 g cefuroxime before
We performed a meta-analysis of modern total
joint
We have reviewed 65 bipolar
We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated. A compartment syndrome of the thigh is a rare, but important complication of
Between 1972 and 1990, we performed 168 primary low-friction
We report a systematic review and meta-analysis
of the peer-reviewed literature focusing on metal sensitivity testing
in patients undergoing total joint replacement (TJR). Our purpose
was to assess the risk of developing metal hypersensitivity post-operatively
and its relationship with outcome and to investigate the advantages
of performing hypersensitivity testing. We undertook a comprehensive search of the citations quoted in
PubMed and EMBASE: 22 articles (comprising 3634 patients) met the
inclusion criteria. The frequency of positive tests increased after
TJR, especially in patients with implant failure or a metal-on-metal
coupling. The probability of developing a metal allergy was higher
post-operatively (odds ratio (OR) 1.52 (95% confidence interval
(CI) 1.06 to 2.31)), and the risk was further increased when failed
implants were compared with stable TJRs (OR 2.76 (95% CI 1.14 to
6.70)). Hypersensitivity testing was not able to discriminate between
stable and failed TJRs, as its predictive value was not statistically
proven. However, it is generally thought that hypersensitivity testing
should be performed in patients with a history of metal allergy
and in failed TJRs, especially with metal-on-metal implants and
when the cause of the loosening is doubtful.
We evaluated the duration of hospitalisation,
occurrence of infections, hip dislocations, revisions, and mortality following
primary hip and knee replacement in 857 patients with Parkinson’s
disease and compared them with 2571 matched control patients. The
data were collected from comprehensive nationwide Finnish health
registers. The mean follow-up was six years (1 to 13). The patients
with Parkinson’s disease had a longer mean length of stay (21 days
[1 to 365] Cite this article:
If patients could recall their physical status
before total hip (THA) or knee arthroplasty (TKA) accurately it
could have valuable applications both clinically and for research.
This study evaluated the accuracy of a patient’s recollection one
year after either THA or TKA using the Oxford hip or knee scores
(OHS and OKS). In total, 113 patients (59 THA, 54 TKA) who had completed
the appropriate score pre-operatively were asked to complete the
score again at a mean of 12.4 months (standard deviation ( While there were no significant differences between the actual
and recalled pre-operative scores (OHS mean difference 0.8, A patient’s recollection of pre-operative pain and function is
inaccurate one year after THA or TKA. Cite this article:
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.
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.
We performed a meta-analysis to evaluate the relative efficacy of regional and general anaesthesia in patients undergoing total hip or knee replacement. A comprehensive search for relevant studies was performed in PubMed (1966 to April 2008), EMBASE (1969 to April 2008) and the Cochrane Library. Only randomised studies comparing regional and general anaesthesia for total hip or knee replacement were included. We identified 21 independent, randomised clinical trials. A random-effects model was used to calculate all effect sizes. Pooled results from these trials showed that regional anaesthesia reduces the operating time (odds ratio (OR) −0.19; 95% confidence interval (CI) −0.33 to −0.05), the need for transfusion (OR 0.45; 95% CI 0.22 to 0.94) and the incidence of thromboembolic disease (deep-vein thrombosis OR 0.45, 95% CI 0.24 to 0.84; pulmonary embolism OR 0.46, 95% CI 0.29 to 0.80). Regional anaesthesia therefore seems to improve the outcome of patients undergoing total hip or knee replacement.
The National Institute for Clinical Excellence (NICE) produces recommendations on appropriate treatment within the National Health Service (NHS) in England and Wales. The NICE guidelines on prophylaxis for venous thromboembolism in orthopaedic surgery recommend that all patients be offered a low molecular weight heparin (LMWH). The linked hospital episode statistics of 219 602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. These were compared with data from the National Joint Registry (England and Wales) regarding the use of LMWH during the same periods. There was a significant increase in the reported use of LMWH (59.5% to 67.6%, p <
0.001) following the publication of the guidelines. However, the 90-day venous thromboembolism events actually increased slightly following total hip replacement (THR, 1.69% to 1.84%, p = 0.06) and remained unchanged following total knee replacement (TKR, 1.99% to 2.04%). Return to theatre in the first 30 days for infection did not show significant changes. There was an increase in the number of patients diagnosed with thrombocytopenia, which was significant following THR (0.11% to 0.16%, p = 0.04). The recommendations from NICE are based on predicted reductions in venous thromboembolism events, reducing morbidity, mortality and costs to the NHS. The early results in orthopaedic patients do not support these predictions, but do show an increase in complications.
An intact barrier between the hands of the surgeon and the patient remains the single most important factor in protection against infection for both. Increasing the awareness of possible glove perforation without skin penetration will decrease the risk of contamination. We performed a prospective, randomised trial comparing the incidence of glove perforation using a new type of glove (Regent Biogel Reveal) and standard double-gloves in total hip and knee replacement. One or more perforations was detected in 14.6% of all gloves. The new gloves increased significantly the awareness of perforation. Multiple perforations at the base of the ring finger were found in surgeons who wore wedding rings during the operation and we recommend that rings be removed before undertaking surgery.
Despite the use of ultraclean air, there are still cases of infection in total joint arthroplasty. One possible route by which bacteria may enter the wound is indirectly by contamination of instruments during skin preparation and draping. We found that bacterial air counts were 4.4 times higher during preparation and draping for hip or knee arthroplasty using an unscrubbed, ungowned leg holder than during the operation itself. With the leg holder scrubbed and gowned during preparation and draping, the air counts were reduced but were still 2.4 fold greater than intraoperatively. On some occasions, the air counts during preparation and draping exceeded the standards for ultraclean air irrespective of the attire of the leg holder. We recommend that the leg is held by a scrubbed and gowned member of the team. More importantly, we consider that instrument packs should be opened only after skin preparation and draping have been completed.
Obtaining a balanced flexion gap with correct
femoral component rotation is one of the prerequisites for a successful
outcome after total knee replacement (TKR). Different techniques
for achieving this have been described. In this study we prospectively
compared gap-balancing Both groups systematically reproduced a similar external rotation
of the femoral component relative to the surgical transepicondylar
axis: 2.4°
Aims. This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists. Methods. All hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Register, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of
Aims. The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. Methods. This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume
Aims. To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. Methods. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. Results. The UK poSt
Aims. Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary
Aims. It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with
Aims. 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
Aims. Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. Methods. We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. Results. In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary
Aims. This study aimed to evaluate whether an enhanced recovery protocol (ERP) for
Aims. The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). Methods. This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National
Aims. It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital. Methods. We analyzed linked hospital and death records for residents of New South Wales, Australia, aged ≥ 18 years who had an emergency readmission within 90 days following THA or TKA surgery between 2003 and 2022. Multivariable modelling was used to identify factors associated with non-index readmission and to evaluate associations of readmission destination (non-index vs index) with 90-day and one-year mortality. Results. Of 394,248
Aims. To investigate factors that contribute to patient decisions regarding attendance for