We recently published a paper comparing the incidence
of adverse outcomes after unicompartmental and total knee arthroplasty
(UKA and TKA). The conclusion of this study, which was in favour
of UKA, was dismissed as “biased” in a review in Cite this article:
Aims. Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery. Methods. A systematic literature search was performed of MEDLINE, Embase, and grey literature databases to include all studies which compare day-case with inpatient knee and hip replacement. Meta-analyses were performed where appropriate using a random effects model. The protocol was registered prospectively (PROSPERO CRD42023392811). Results. A total of 38 studies were included, with a total of 83,888 day-case procedures. The studies were predominantly from the USA and Canada, observational, and with a high risk of bias. Day-case patients were a mean of 2.08 years younger (95% CI 1.05 to 3.12), were more likely to be male (odds ratio (OR) 1.3 (95% CI 1.19 to 1.41)), and had a lower mean BMI and American Society of Anesthesiologists grades compared with inpatients. Overall, day-case surgery was associated with significantly lower odds of readmission (OR 0.83 (95% CI 0.73 to 0.96); p = 0.009), subsequent emergency department attendance (OR 0.62 (95% CI 0.48 to 0.79); p < 0.001), and complications (OR 0.7 (95% CI 0.55 to 0.89) p = 0.004), than inpatient surgery. There were no significant differences in the rates of reoperation or mortality. The overall rate of successful same-day discharge for day-case surgery was 85% (95% CI 81 to 88). Patient-reported outcome measures and cost-effectiveness were either equal or favoured day-case. Conclusion. Within the limitations of the literature, in particular the substantial risk of selection
For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients. The Hospital Quality Monitoring System was queried from 1 January 2013 to 31 December 2019 for displaced FNFs in geriatric patients treated with THA or HA. After propensity score matching, which identified 33,849 paired patients, outcomes were compared between THA and HA using logistic and linear regression models.Aims
Methods
In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility. Patients with PJI of the knee and subsequent KA or AKA between June 2011 and May 2021 were included. Demographic data, comorbidities, and patient history were analyzed. Functional outcomes and QoL were prospectively assessed in both groups with additional treatment-specific scores after AKA. Outcomes, complications, and mortality were evaluated.Aims
Methods
We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes.Aims
Methods
Aims. The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. Patients and Methods. A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection
There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively.Aims
Methods
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. 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 length of hospital stay.Aims
Methods
Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery.Aims
Methods
Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties. Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosisAims
Methods
The application of robotics in the operating theatre for knee arthroplasty remains controversial. As with all new technology, the introduction of new systems might be associated with a learning curve. However, guidelines on how to assess the introduction of robotics in the operating theatre are lacking. This systematic review aims to evaluate the current evidence on the learning curve of robot-assisted knee arthroplasty. An extensive literature search of PubMed, Medline, Embase, Web of Science, and Cochrane Library was conducted. Randomized controlled trials, comparative studies, and cohort studies were included. Outcomes assessed included: time required for surgery, stress levels of the surgical team, complications in regard to surgical experience level or time needed for surgery, size prediction of preoperative templating, and alignment according to the number of knee arthroplasties performed. A total of 11 studies met the inclusion criteria. Most were of medium to low quality. The operating time of robot-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is associated with a learning curve of between six to 20 cases and six to 36 cases respectively. Surgical team stress levels show a learning curve of seven cases in TKA and six cases for UKA. Experience with the robotic systems did not influence implant positioning, preoperative planning, and postoperative complications. Robot-assisted TKA and UKA is associated with a learning curve regarding operating time and surgical team stress levels. Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. The prior experience of the surgical team should also be evaluated and reported. Cite this article:
To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes’ disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes’ disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either ‘in’ or ‘out’) before a final consensus meeting with representatives of surgeons, patients, and parents.Aims
Methods
The aims of this study were to characterize the frequency of
missing data in the National Surgical Quality Improvement Program
(NSQIP) database and to determine how missing data can influence
the results of studies dealing with elderly patients with a fracture
of the hip. Patients who underwent surgery for a fracture of the hip between
2005 and 2013 were identified from the NSQIP database and the percentage
of missing data was noted for demographics, comorbidities and laboratory
values. These variables were tested for association with ‘any adverse
event’ using multivariate regressions based on common ways of handling
missing data.Aims
Patients and Methods
The aim of this meta-analysis was to assess the safety and efficacy
of collagenase clostridium histolyticum compared with fasciectomy
and percutaneous needle fasciotomy (PNF) for Dupuytren’s disease. We systematically searched PubMed, EMBASE, LILACS, Web of Science,
Cochrane, Teseo and the ClinicalTrials.gov registry for clinical
trials and cohort or case-control studies which compared the clinical
outcomes and adverse effects of collagenase with those of fasciectomy
or PNF. Of 1345 articles retrieved, ten were selected. They described
the outcomes of 425 patients treated with collagenase and 418 treated
by fasciectomy or PNF. Complications were assessed using inverse-variance
weighted odds ratios (ORs). Clinical efficacy was assessed by differences
between the means for movement of the joint before and after treatment.
Dose adjustment was applied in all cases.Aims
Materials and Methods
Flail chest from a blunt injury to the thorax is associated with
significant morbidity and mortality. Its management globally is
predominantly non-operative; however, there are an increasing number
of centres which undertake surgical stabilisation. The aim of this
meta-analysis was to compare the efficacy of this approach with
that of non-operative management. A systematic search of the literature was carried out to identify
randomised controlled trials (RCTs) which compared the clinical
outcome of patients with a traumatic flail chest treated by surgical
stabilisation of any kind with that of non-operative management.Aims
Patients and Methods
Total knee arthroplasty (TKA) is an established
and successful procedure. However, the design of prostheses continues
to be modified in an attempt to optimise the functional outcome
of the patient. The aim of this study was to determine if patient outcome after
TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%),
81 male (32%)) were enrolled in a single centre double-blind trial
and randomised to receive either a Kinemax (group 1) or a Triathlon
(group 2) TKA. Patients were assessed pre-operatively, at six weeks, six months,
one year and three years after surgery. The outcome assessments
used were the Oxford Knee Score; range of movement; pain numerical
rating scales; lower limb power output; timed functional assessment
battery and a satisfaction survey. Data were assessed incorporating
change over all assessment time points, using repeated measures
analysis of variance longitudinal mixed models. Implant group 2
showed a significantly greater range of movement (p = 0.009), greater
lower limb power output (p = 0.026) and reduced report of ‘worst
daily pain’ (p = 0.003) over the three years of follow-up. Differences
in Oxford Knee Score (p = 0.09), report of ‘average daily pain’
(p = 0.57) and timed functional performance tasks (p = 0.23) did
not reach statistical significance. Satisfaction with outcome was
significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced
by the prosthesis used. Cite this article:
The Oxford hip and knee scores (OHS and OKS)
are validated patient-reported outcome measures used in patients undergoing
total hip replacement (THR), hip resurfacing (HR), total knee replacement
(TKR) and unicompartmental knee replacement (UKR). We analysed the
absolute OHS and OKS and change in scores following THR, HR, TKR,
and UKR performed at one specialist centre. All patients undergoing
and completing at least one Oxford score were eligible for inclusion
in the study which included 27 950 OHS and 19 750 OKS in 13 682
patients. Data were analysed using non-linear quantile regression.
The median absolute Oxford scores for THR, HR, TKR and UKR were
pre-operative 68.8% (15.0/48), 58.3% (20.0/48), 66.7% (16.0/48),
60.4% (19.0/48) respectively: and post-operative asymptote was 14.6%
(41.0/48), 5.8% (45.2/48), 31.2% (33.0/48), 29.2% (34.0/48). The
median asymptotic change from the pre-operative score for THR, HR,
TKR and UKR were 47.9% (23.0/48), 47.9% (23.0/48), 33.3% (16.0/48)
and 32.4% (15.5/48), respectively. The median time at which no further
appreciable change in score was achieved post-operatively was 0.7
years for THR, 1.1 years for HR, 0.9 years for TKR and 1.1 years
for UKR. The curves produced from this analysis could be used to educate
patients, and to audit the performance of a surgeon and an institution.
The time to achieve a stable improvement in outcome varied between
different types of joint replacement, which may have implications
for the timing of post-operative review. Cite this article:
This prospective study assessed the effect of social deprivation on the Oxford hip score at one year after total hip replacement. An analysis of 1312 patients undergoing 1359 primary total hip replacements for symptomatic osteoarthritis was performed over a 35-month period. Social deprivation was assessed using the Carstairs index. Those patients who were most deprived underwent surgery at an earlier age (p = 0.04), had more comorbidities (p = 0.02), increased severity of symptoms at presentation (p = 0.001), and were not as satisfied with their outcome (p = 0.03) compared with more affluent patients. There was a significant improvement in Oxford scores at 12 months relative to pre-operative scores for all socioeconomic categories (p <
0.001). Social deprivation was a significant independent predictor of mean improvement in Oxford scores at 12 months, after adjusting for confounding variables (p = 0.001). Deprivation was also associated with an increased risk of dislocation (odds ratio 5.3, p <
0.001) and mortality at 90 days (odds ratio 3.2, p = 0.02). Outcome, risk of dislocation and early mortality after a total hip replacement are affected by the socioeconomic status of the patient
Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices. We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively. The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.
We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.
