Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009: from research to implementation

Machine learning for predicting duration of surgery and length of stay: A literature review on joint arthroplasty

INTRODUCTION

In recent years, different factors such as population aging have caused escalating demand for hip and knee arthroplasty straining already limited hospitals' resources. To address this challenge, focus is put on medical and operational efficiency improvements. This includes an increased use of machine learning (ML) to predict duration of surgery (DOS) and length of stay (LOS) for total knee and total hip arthroplasty, which can be utilized for optimizing resource allocation to satisfy medical and operational limitations. This paper explores the development and performance of ML models in predicting DOS and LOS.

METHODS

A systematic search of publications between 2010-2023 was conducted following PRISMA guidelines. Considering the inclusion and exclusion criteria, 28 out of 722 gathered papers from PubMed, Web of Science, and manual search were included in the study. Descriptive statistics was used to analyze the extracted data regarding data preprocessing, model development, and model performance assessment.

RESULTS

Most of the papers work on LOS as a binary variable. Patient's age was identified as the most frequently used and reported as important variable for predicting DOS and LOS. Investigations also illustrated that within the resulting 28 papers, more than 71% of models reached good to perfect performance based on the area under the receiver operating characteristic curve (AUC), where artificial neural networks and ensemble learning models had the biggest share among the best-performing models.

CONCLUSION

The utilization of ML models is increasing in the literature. The current performance level indicates that ML can potentially turn to powerful tools in predicting DOS and LOS for different purposes. Meanwhile, the literature is not matured yet in reporting real-life application. Future studies can focus on model specification and validation by considering empirical application.

Metabolic syndrome increases the length of stay and medical complications after hip and knee arthroplasty: results from a prospective cohort study of 2,901 patients

BACKGROUND AND PURPOSE

 Metabolic syndrome (MetS) affects more than 60% of the patients having a hip or knee arthroplasty due to osteoarthritis. As it is debated whether metabolic syndrome increases the risk of complications, we aimed to investigate the length of stay (LOS) and risk of readmission at 30 and 90 days after surgery, including causes of readmission.

METHODS

 We conducted a prospective cohort study of 2,901 patients undergoing hip and knee arthroplasty from May 2017 to November 2019. Physical examination, blood samples, and medical history from national registries determined the diagnosis of metabolic syndrome from the International Diabetes Federation definition. We used multivariate linear regression to investigate differences in LOS according to MetS, and binary regression to investigate the risk and causes of readmission within 30 and 90 days, including 95% confidence intervals (CI) and P values.

RESULTS

 Patients with MetS showed a slightly longer LOS (0.20 days, CI 0.10-0.29) and had an increased risk of readmission within 90 days (adjusted relative risk [RR] 1.2, CI 1.0-1.4; P = 0.02), but not within 30 days (adjusted RR 1.1, CI 0.9-1.4; P = 0.3) after surgery. Cardiovascular disease was the dominant cause of readmission.

CONCLUSION

Although patients with MetS do not experience a clinically relevant longer LOS after hip and knee arthroplasty, they have an increased risk of 90-day readmission mainly due to cardiovascular complications, which should be considered when planning surgical care in this group of patients.

Patient-reported outcomes the first thirty days after fast-track primary total hip arthroplasty. A prospective cohort study using a web-based registration tool for postoperative follow-up

INTRODUCTION

The documentation on patient reported outcomes the first weeks at home following total hip arthroplasty (THA) is sparse. Length of hospital stay after THA is substantially reduced. Therefore, knowledge on whether patients are managing their own postoperative rehabilitation early after discharge is important, in order to give the patients realistic preoperative information, to modify expectations and enable patients to monitor their own rehabilitation process.

METHODS

Eighty-two THA patients were included in a prospective cohort study. Patient-reported outcomes were collected twice a week thirty days postoperatively using a web-based registration tool. Numeric rating scales (0-10) for pain, function, and quality of life, EQ-5D, and the use of opioids were registered. Four weeks postoperatively a telephone interview were conducted. Pain, EQ5D and hip specific physical function score (HOOS-PS) were recorded preoperatively, at three- and twelve-months follow-up.

RESULTS

Pain was maintained the first days after hospital discharge. From day 0 to day 30, pain decreased from 4.0 (SD 2.23) to 2.3 (SD 1.75), function improved from 4.4 (SD 2.06) to 7 (SD 1.57), quality of life improved from 6.3 (SD 2.69) to 7.8 (SD 1.47), and EQ-5D improved from 0.4 to (SD 0.27) to 0.7 (SD 0.14). After 30 days, 32% still used opioids. All patients completed the web-registration. Pain, EQ-5D and HOOS-PS improved substantially from preoperatively to twelve months follow-up.

CONCLUSION

Fast-track THA patients can expect continued postoperative pain and impaired quality of life the first week at home, before gradually improvement. After thirty days, 32 % of the patients still used opioids.

Stepwise implementation of an enhanced recovery pathway for elective total hip arthroplasty in a Swiss hospital: a cohort study

BACKGROUND

Enhanced recovery programs after total hip arthroplasty have been shown to reduce hospital length of stay without compromising results, but yet there is a lack of data for the Swiss population. Therefore, this retrospective cohort study evaluated whether similar positive effects on clinical outcomes are present in the context of the Swiss healthcare system.

METHODS

Patients who underwent elective primary total hip arthroplasty were analysed. The baseline group comprised 50 patients treated consecutively by one surgeon in 2013 according to the clinical practice guidelines. Another surgeon implemented a new standardised treatment protocol in April 2014. In January 2018, this protocol was followed by an enhanced recovery program that integrated all care providers at the hospital. The data of the baseline group (series 0) and four series of 50 patients each, two treated with the standardised treatment protocol (series 1-2) and two treated with the enhanced recovery program (series 3-4), were analysed. All patients had follow-ups at 6 weeks and 3 months after surgery. The primary outcomes were length of stay and discharge destination; the secondary outcomes were admission on the day of surgery (instead of one day prior), the use of urinary catheters, the administration of opioids, the difference between pre- and postoperative haemoglobin, blood transfusions, and adverse events within 3 months of surgery.

RESULTS

The median length of stay was 10 days in the baseline group and only 5 days after the implementation of the standardised protocol and enhanced recovery program in series 4 (p <0.001). The percentage of patients discharged directly home was higher in series 4 than in the baseline group (84% vs. 66%, p = 0.085). Patients admitted to the hospital on the day of surgery increased from 2% in series 0 to 98% in series 4 (p <0.001). The use of urinary catheters was significantly higher in the baseline group (100% of patients) than in series 3 and 4 (0%) (p <0.001), and the number of patients who did not require opioids was significantly higher in series 4 than in series 0 (36% vs. 10%, p = 0.007). The median blood loss (500 ml vs. 300 ml, p <0.001), median difference in pre- and postoperative haemoglobin (29 g/dl vs. 25 g/dl, p = 0.145), and number of blood transfusions (5 vs. 2 p = 0.99) were higher in the baseline group than in series 4. The number of adverse events did not differ significantly between groups (p = 0.699).

CONCLUSIONS

Almost all parameters examined in this study showed improvement, whereas the rate of adverse events was not affected and remained low. The presented data can be used as a benchmark, but details of these findings need to be confirmed in larger cohorts.

Discharge From the Postanesthesia Care Unit With Motor Blockade After Spinal Anesthesia Safely Optimizes Fast Track Recovery in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Post anesthesia care units (PACU) await return of motor function in lower extremities, prior to discharge for patients undergoing spinal anesthesia. The purpose of this study was to assess the impact of a newly utilized recovery protocol that facilitated early discharges of patients undergoing total hip and knee arthroplasties (THA/TKA) to the floor before full motor recovery from spinal anesthesia is achieved.

METHODS

A total of 647 patients undergoing spinal anesthesia for primary THA (n = 190) and TKA (n = 457) were divided into 2 groups: (1) Early PACU discharge group: patients with partial or full motor blockade at discharge. (2) Control PACU discharge group: patients with full motor recovery at discharge. Readiness for discharge was assessed using a modified Aldrete Score system. The primary outcome was incidences of hypotension or rapid responses post-operatively.

RESULTS

There was no significant difference in the incidence of hypotension between the two groups (1.4 versus 1.39%, P = 1.0) and zero rapid responses were noted. Early discharge shortened mean PACU LOS time from 86.50 minutes to 70.27 minutes (P < .01). There was no difference in the incidence of nausea (0.55 versus 0%; P = .51) ordizziness (2.22 versus 0.35%; P = .09).

CONCLUSION

In this retrospective observational study, we found that early PACU discharge did not result in an increase in hemodynamic consequences on the surgical floor. Thus, discharge from PACU can be safely and more expeditiously performed without waiting for return of motor function in patients receiving spinal anesthesia for THA/TKA using a modified Aldrete Score recovery protocol.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Establishment of a qualified integrated care system after total knee arthroplasty as a role of regional rheumatoid and degenerative arthritis centers

BACKGROUND

The geriatric population and advanced knee osteoarthritis are rapidly increasing in Korea, and the socioeconomic burden of total knee arthroplasty (TKA) is increasing. This study aimed to analyze the demographic, clinical and socioeconomic characteristics of patients who underwent TKA and to differentiate the factors affecting participation in inpatient-intensive rehabilitation programs after TKA in the Jeju regional rheumatoid and degenerative arthritis center established by the government.

METHODS

This retrospective cohort study included 845 patients (735 females; 72.0 ± 5.8 years) diagnosed with primary osteoarthritis (OA) of the knee who underwent elective unilateral primary TKA between January 2013 and June 2016. Demographic, clinical, and socioeconomic characteristics, including age, body mass index, obesity, length of stay, OA severity, underlying disease, education level, occupation, and location of residence were reviewed. Patients were allocated to the TKA-only group (home discharge) and to the TKA + rehab group (participation in post-TKA rehabilitation). The variables were analyzed and compared before and after the establishment of the center and according to participation in intensive rehabilitation.

RESULTS

Patients who underwent TKA were mostly female, in the 60 s, and had a high prevalence of comorbidities and obesity. After the rehabilitation center's establishment, the intensive post-TKA participation increased profoundly from 3% to 59.2%. Participants after the center establishment had lower mean BMI and a higher proportion of K-L grade 4 compared to those before the center establishment. The location of residence was the only factor differentiating the participation in the intensive rehabilitation.

CONCLUSION

The regional rheumatoid and degenerative arthritis center was appropriate to satisfy the high unmet need for participating in the intensive rehabilitation after TKA and to execute the qualified integrated post-TKA care system. Policy support should ensure the early rehabilitation and a qualified integrated care system and prepare for the increased burden of revision. Future longitudinal studies should be conducted to assess the long-term effect of the integrated post-TKA rehabilitation program on functional outcomes and patient survivorship free from revision.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Is It Possible to Predict the Length of Stay of Patients Undergoing Hip-Replacement Surgery?

The proximal fracture of the femur and hip is the most common reason for hospitalization in orthopedic departments. In Italy, 115,989 hip-replacement surgeries were performed in 2019, showing the economic relevance of studying this type of procedure. This study analyzed the data relating to patients who underwent hip-replacement surgery in the years 2010-2020 at the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital of Salerno. The multiple linear regression (MLR) model and regression and classification algorithms were implemented in order to predict the total length of stay (LOS). Lastly, using a statistical analysis, the impact of COVID-19 was evaluated. The results obtained from the regression analysis showed that the best model was MLR, with an R² value of 0.616, compared with XGBoost, Gradient-Boosted Tree, and Random Forest, with R² values of 0.552, 0.543, and 0.448, respectively. The t-test showed that the variables that most influenced the LOS, with the exception of pre-operative LOS, were gender, age, anemia, fracture/dislocation, and urinary disorders. Among the classification algorithms, the best result was obtained with Random Forest, with a sensitivity of the longest LOS of over 89%. In terms of the overall accuracy, Random Forest and Gradient-Boosted Tree achieved a value of 71.76% and an error of 28.24%, followed by Decision Tree, with an accuracy of 71.13% and an error of 28.87%, and, finally, Support Vector Machine, with an accuracy of 65.06% and an error of 34.94%. A significant difference in cardiovascular disease, fracture/dislocation, and post-operative LOS variables was shown by the chi-squared test and Mann-Whitney test in the comparison between 2019 (before COVID-19) and 2020 (in full pandemic emergency conditions).

Determination of Factors Affecting Early Mobilization of Patients Who Have Undergone Knee and Hip Arthroplasty

PURPOSE

This study was conducted in order to determine the factors that affected the early mobilization after surgery of patients who had undergone knee and hip arthroplasty.

DESIGN

This study is descriptive correlational.

METHODS

The study population consists patients who met the inclusion criteria and were hospitalized in a State Hospital Orthopedics and Traumatology Clinic in Turkey in order have the knee or hip arthroplasty surgery between the dates of November 7, 2017 and September 21, 2018. While selecting the sample, the purposive sampling method was used. The sample consists of 60 patients who were in the universe of the study, who meet the inclusion criteria and who voluntarily agreed to participate in the study.

FINDINGS

The mean time of the first mobilization of the patients was 19 (9.15-72) hours. There were statistically significant relationships between mobilization time and age, gender, marital status, body mass index, past surgical history, chronic pain, blood transfusion before surgery, medical diagnosis, surgical procedure, bone cement usage, the score for American society of Anesthesiologists, surgical intervention time, post-operation nutrition, and defecation time.

CONCLUSION

The early mobilization time of the great majority of the patients who underwent knee and hip arthroplasty was in conformity with the enhanced recovery after surgery protocol.

Complications of total hip or knee arthroplasty are not significantly more common after ambulatory surgery than after in-patient surgery and enhanced recovery: A case-control study with propensity-score matching

BACKGROUND

Reluctance to perform total hip arthroplasty (THA) and total knee arthroplasty (TKA) on an ambulatory basis stems from concern that complications might be more common than with enhanced recovery after surgery (ERAS). The objective of this study was to compare the risks of complications, readmission, and reoperation with these two strategies.

HYPOTHESIS

The complication rate is significantly higher after ambulatory surgery (AS) than with ERAS.

MATERIAL AND METHODS

Consecutive patients who underwent primary unilateral THA or TKA by two senior surgeons to treat a non-traumatic condition between July 2016 and December 2019 were eligible. We developed a propensity score, which we used to individually match each of the 91 patients managed by AS to the 91 patients managed with ERAS (control group). Follow-up was 3 months. The primary outcome was development of a complication within the first 3 months. Secondary outcomes were complication severity as classified according to Clavien-Dindo, re-admissions within 3 months, and re-operations within 3 months.

RESULTS

Complications were not significantly more common after AS than with ERAS (15% and 11%, respectively, p=0.38). No significant differences were found between the two groups for complication severity (2.9±0.5 versus 2.6±0.8), proportion of re-admitted patients (14% versus 9%), or proportion of re-operated patients (14% versus 9%).

DISCUSSION

The risk of complications was not higher after AS than with ERAS. Reluctance to perform AS due to concern about safety does not seem justified by the evidence.

LEVEL OF EVIDENCE

III, propensity score-matched case-control study.

Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients

INTRODUCTION

Studies investigating complications between octogenarians and non-octogenarians undergoing primary total knee arthroplasty (TKA) are limited. Therefore, we investigated whether octogenarians are at greater odds of: (1) in-hospital lengths of stay (LOS) (2) readmission rates, (3) medical complications, and (4) hardware complications compared to non-octogenarians following TKA.

METHODS

A retrospective query of the PearlDiver database isolated 1,775,460 patients who underwent primary TKA from 2005 to 2014. Patients aged 80 and above represented the study cohort (n = 295,908) and patients 65 to 79 represented the control cohort (n = 1,479,552). Study group patients were matched to controls in a 1:5 ratio according to gender and medical comorbidities. Pearson's Chi Square and logistic regression were used to analyze the primary outcomes of the study which included 90-day medical complications, 90-day readmission rates, 2-year implant-related complications, and in-hospital LOS. A p-value less than 0.001 was statistically significant.

RESULTS

Octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates (10.59 vs. 9.35%; OR: 1.15, p < 0.0001) and significantly longer in-hospital LOS (3.69 days ± 1.95 vs. 3.23 days ± 1.83, p < 0.0001) compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication (1.26 vs. 1.26%; OR: 0.99, p = 0.99) and lower incidence and odds (1.67 vs. 1.93%; OR: 0.86, p < 0.001) of implant-related complications compared to controls.

CONCLUSION

Octogenarians undergoing primary TKA have similar odds of medical related complications and lower odds of implant-related complications compared to non-octogenarian patients, whereas readmission rates and in-hospital LOS are greater.

Conventional versus fast track rehabilitation after total hip replacement: A randomized controlled trial

Background: Total hip replacement (THR) is currently the most successful orthopaedic operation worldwide. This success is, however, dependent on the quality and efficiency of postoperative rehabilitation programs following it. Methods: In a randomized controlled trial (RCT), sixty patients (32 females, 28 males, mean age 68.4 years) undergoing THR for hip arthritis having either a conventional rehabilitation after a normal hospital stay (30 patients) or a fast track rehabilitation program (30 patients) were compared. Results: The mean length of stay in the conventional group was 7.8 (range: 6–11) days compared to 4.5 (range 3–5) days in the fast track group ( p  = <0.001). Complications included one dislocation in either group, a case of heart failure and a readmission in the conventional group. As regards functional outcome, patients in the conventional group had a mean Harris Hip Score of 69.3 six weeks and 82 twelve weeks postoperatively in comparison to 79 and 91 in the fast track group respectively. The differences were statistically significant ( p = 0.013 and 0.002 respectively). Conclusion: Fast track rehabilitation after THR allows early patient's mobilization and shorter hospital stay with better functional outcome and without increasing the risk of complications or the readmission rate.

Construction and Comparison of Predictive Models for Length of Stay after Total Knee Arthroplasty: Regression Model and Machine Learning Analysis Based on 1,826 Cases in a Single Singapore Center

The purpose of this study was to develop a predictive model for length of stay (LOS) after total knee arthroplasty (TKA). Between 2013 and 2014, 1,826 patients who underwent TKA from a single Singapore center were enrolled in the study after qualification. Demographics of patients with normal and prolonged LOS were analyzed. The risk variables that could affect LOS were identified by univariate analysis. Predictive models for LOS after TKA by logistic regression or machine learning were constructed and compared. The univariate analysis showed that age, American Society of Anesthesiologist level, diabetes, ischemic heart disease, congestive heart failure, general anesthesia, and operation duration were risk factors that could affect LOS (p < 0.05). Comparing with logistic regression models, the machine learning model with all variables was the best model to predict LOS after TKA, of whose area of operator characteristic curve was 0.738. Machine learning algorithms improved the predictive performance of LOS prediction models for TKA patients.

Enhanced Recovery After Primary Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission.

RESULTS

Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates.

CONCLUSIONS

ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

PURPOSE

We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.

METHODS

200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.

RESULTS

166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%.

CONCLUSION

Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Participation in a Preoperative Patient Education Session Is a Significant Predictor of Better WOMAC Total Index Score and Higher EQ-5D-5L Health Status Index 1 Year After Total Knee and Hip Arthroplasties: A Retrospective Observational Study

OBJECTIVE

The aim of the study was to investigate whether patient-specific factors, preoperative patient-reported outcome measures, and participation in a preoperative patient education session significantly predict 1-yr Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) health status index of patients who underwent total hip or knee arthroplasties within an enhanced rehabilitation program.

DESIGN

This is a retrospective observational cohort study. The inclusion criteria were met by 676 (373 total hip arthroplasties and 303 total knee arthroplasties) patients. Two multiple regression models were carried out to estimate the contributions of nine potential predictors.

RESULTS

Younger age (P = 0.006), higher preoperative EQ-5D-5L index (P = 0.004), lower patient clinical complexity level (P = 0.001), lower preoperative WOMAC total score (P < 0.001), preoperative patient education session (P = 0.004), and submitting for total hip arthroplasty (P < 0.001) were significant predictors of better 1-yr WOMAC total score. Higher preoperative EQ-5D-5L index (P < 0.001), lower patient clinical complexity level classification (P < 0.001), lower preoperative WOMAC total score (P = 0.009), preoperative patient education session (P = 0.04), and submitting for total hip arthroplasty (P = 0.01) were significant predictors of higher 1-yr EQ-5D-5L health status index.

CONCLUSIONS

Better baseline patient-reported outcome measure scores, less comorbidities, younger age, submitting for total hip arthroplasty, and attending a preoperative patient education session were significant predictors of better WOMAC total scores and higher EQ-5D-5L health status index 1 yr after total hip or total knee arthroplasties.

MRI Assessment of Muscle Damage After the Posterolateral Versus Direct Anterior Approach for THA (Polada Trial). A Randomized Controlled Trial

BACKGROUND

There is controversy in literature whether the direct anterior approach (DAA) results in less muscle damage compared with the posterolateral approach (PLA) for total hip arthroplasty. The aim of this randomized controlled trial was to assess muscle damage between these two approaches.

METHODS

Forty-six patients were included. Muscle atrophy, determined with the Goutallier classification, and muscle surface of twelve muscles were analyzed on magnetic resonance imaging images made preoperatively and one year postoperatively. Differences in component placement after DAA or PLA were assessed on radiographs. Harris hip scores and Hip disability and Osteoarthritis and Outcome Score were used as functional outcomes.

RESULTS

External rotator musculature was damaged in both approaches. After PLA, the obturator muscles showed significantly more atrophy and a decrease in muscle surface. After DAA, the tensor fascia latae showed an increased muscle atrophy and the psoas muscle showed a decreased muscle surface. An increase in muscle surface was seen for the rectus femoris, sartorius, and quadratus femoris after both approaches. The muscle surface of the gluteus medius and iliacus was also increased after PLA. No difference in muscle atrophy was found between the approaches for these muscles. The inclination angle of the cup in PLA was significantly higher. No differences were found in functional outcomes.

CONCLUSION

Different muscle groups were affected in the two approaches. After PLA, the external rotators were more affected, whereas the tensor fascia latae and psoas muscles were more affected after DAA.

Association between surgical wait time and hospital length of stay in primary total knee and hip arthroplasty

AIMS

In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip.

METHODS

The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression.

RESULTS

A total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS.

CONCLUSION

Surgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS. Cite this article: Bone Jt Open 2021;2(8):679-684.

Superior Functional Outcome and Comparable Health-Related Quality of Life after Enhanced Recovery vs. Conventional THA: A Retrospective Matched Pair Analysis

BACKGROUND

The concept of enhanced recovery after total hip arthroplasty is gaining worldwide interest, as it shortens the length of hospital stay without an increase of complications. The aim of the study was to investigate the functional outcome and health-related quality of life 12 months after cementless total hip arthroplasty with the use of an enhanced recovery concept in comparison to a conventional rehabilitation.

MATERIAL AND METHODS

320 patients were retrospectively analyzed who underwent primary cementless total hip arthroplasty (THA). A total of 123 of the patients received an enhanced recovery program (ERAS) and 197 patients a conventional rehabilitation (Non-ERAS). Twelve months postoperatively, a clinical examination was performed regarding satisfaction, function and pain. Results were evaluated using WOMAC, EQ-5D-5L and EQ-VAS. A 1:1 matching was performed to correct for confounding variables, regarding age, sex and ASA score. Finally, 122 patients (n = 61, in each group) were analyzed and compared.

RESULTS

Patients showed a significant improvement of WOMAC total score, subscale pain, subscale stiffness and subscale function from preoperative to the follow up after 12 months in both groups, with significantly superior results for the WOMAC total score for the ERAS group (p = 0.042). EQ-5D and EQ-5D VAS showed a significant improvement from preoperative to 12 months postoperative (p < 0.001) for both groups, while no difference regarding the group-comparison was shown.

CONCLUSION

Health-related quality of life and functional outcome increased to excellent values after total hip arthroplasty with the use of an enhanced recovery concept and a conventional rehabilitation, with a superior WOMAC total score for ERAS and a tendency to better results for health-related quality of life for patients with ERAS within the follow up after 12 months.

Excellent Functional Outcome and Quality of Life after Primary Cementless Total Hip Arthroplasty (THA) Using an Enhanced Recovery Setup

Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction; results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p < 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p < 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p < 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction.

Bleeding complications of thromboprophylaxis with dabigatran, nadroparin or rivaroxaban for 6 weeks after total knee arthroplasty surgery: a randomised pilot study

OBJECTIVES

For the non-vitamin-K oral anticoagulants, data on bleeding when used for 42 days as thromboprophylaxis after total knee arthroplasty (TKA) are scarce. This pilot study assessed feasibility of a multicentre randomised clinical trial to evaluate major and clinically relevant non-major bleeding during 42-day use of dabigatran, nadroparin and rivaroxaban after TKA.

PATIENTS AND METHODS

In 70 weeks, between July 2012 and November 2013, 198 TKA patients were screened for eligibility in the Martini Hospital (Groningen, the Netherlands). Patients were randomly assigned to dabigatran (n=45), nadroparin (n=45) or rivaroxaban (n=48). The primary outcome was the combined endpoint of major bleeding and clinically relevant non-major bleeding. Secondary endpoints of this study were the occurrence of clinical venous thromboembolism (VTE) (pulmonary embolism or deep venous thrombosis), compliance, duration of hospital stay, rehospitalisation, adverse events and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

The primary outcome was observed in 33.3% (95% CI 20.0% to 49.0%), 24.4% (95% CI 12.9% to 39.5%) and 27.1% (95% CI 15.3% to 41.8%) of patients who received dabigatran, nadroparin or rivaroxaban, respectively (p=0.67). Major bleeding was found in two patients who received nadroparin (p=0.21). Clinically relevant non-major bleeding was observed in 33.3% (95% CI 20.0% to 49.0%), 22.2% (95% CI 11.2% to 37.1%) and 27.1% (95% CI 15.3% to 41.8%) for dabigatran, nadroparin and rivaroxaban, respectively (p=0.51). Wound haematoma was the most observed bleeding event. VTE was found in one patient who received dabigatran (p=0.65). The presurgery and postsurgery KOOS qQuestionnaires were available for 32 (71%), 35 (77%) and 35 (73%) patients for dabigatran, nadroparin and rivaroxaban, respectively. KOOS was highly variable, and no significant difference between treatment groups in mean improvement was observed.

CONCLUSIONS

A multicentre clinical trial may be feasible. However, investments will be substantial. No differences in major and clinically relevant non-major bleeding events were found between dabigatran, nadroparin and rivaroxaban during 42 days after TKA. KOOS may not be suitable to detect functional loss due to bleeding.

TRIAL REGISTRATION NUMBER

NCT01431456.

Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017

“Fast-track” protocols has improved surgical care with a reduction in length of hospital stay (LOS) in total hip (THA) and knee arthroplasty (TKA). However, the effects of continuous refinement of perioperative care lack detailed assessment. We studied time-related changes in LOS and morbidity after THA and TKA within a collaboration with continuous scientific refinement of perioperative care. Prospective multicentre consecutive cohort study between 2010 and 2017 from nine high-volume orthopaedic centres with established fast-track THA and TKA protocols. Prospective collection of comorbidities and complete 90-day follow-up from the Danish National Patient Registry and medical records. Of 36,935 procedures median age was 69 [62 to 75] years and 58% women. LOS declined from three [two to three] days in 2010 to one [one to two] day in 2017. LOS > 4 days due to “medical” or “surgical” complications, and “with no recorded morbidity” declined from 4.4 to 2.7%, 1.5 to 0.6%, and 3.8 to 1.3%, respectively. 90-days readmission rate declined from 8.6 to 7.7%. Our multicentre study in a socialized healthcare setting was associated with a continuous reduction in LOS and morbidity after THA and TKA.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program

INTRODUCTION

Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol.

HYPOTHESIS

The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol.

METHODS

This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months.

RESULTS

Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA.

DISCUSSION

The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed.

LEVEL OF EVIDENCE

IV; Prospective cohort study without control group.

Fast track protocol for primary total hip arthroplasty in non-trauma cases reduces the length of hospital stay: Prospective French multicenter study

BACKGROUND

Fast-track (FT) procedures continue to evolve; however, their benefits are still controversial. This led us to conduct a prospective study of FT procedures for total hip arthroplasty (THA) on a national scale in France with historical control data. The aims were to (1) evaluate the effectiveness of FT procedures after THA on the length of hospital stay (LOS) in a multicenter analysis, (2) measure the immediate return to home, rehospitalization and reoperation rates.

HYPOTHESIS

FT procedures reduce the LOS after primary THA for non-traumatic indications relative to national historical data.

METHODS

A prospective observational study was done at 11 hospital facilities throughout France. Patients who underwent primary THA for a non-traumatic condition and FT procedures were followed for 3 months. The average LOS, discharge to home, unexpected readmissions, and reoperation rate were compared to 2016 figures from the French national database of 104,745 procedures on the same population.

RESULTS

The study included 1,110 patients, 499 men (45%) and 611 women (55%), with a mean age of 67.5±11.9 years. The average LOS was 3.3±2.9 days versus 7.5±5.3 days in the national database (p<0.001). Eight hundred eighty patients (79%) were discharged directly to home versus 72,577 (69%) in the national database (p<0.001). Forty-two patients (4%) were readmitted to the hospital within 90 days of the THA versus 11,092 (11%) in the national database (p<0.001). Eighteen patients (1.6%) were reoperated within 90 days of the THA procedure versus 2100 (2.0%) in the national database (p=0.72).

DISCUSSION

FT procedures help to significantly reduce the average LOS and rehospitalization rate after primary THA for non-traumatic conditions and significantly increased the percentage of patients being discharged directly to home relative to national historical data, without altering the risk of reoperation. FT procedures should become the standard of care after THA.

LEVEL OF EVIDENCE

III; prospective case-control study.

Fast-track rehabilitation after total knee arthroplasty reduces length of hospital stay: A prospective, case-control clinical trial

Objectives

The aim of this study was to compare the impact of fast-track rehabilitation (FTR) and conventional rehabilitation (CR) on early recovery pattern after fast-track surgery for knee arthroplasty and conventional total knee arthroplasty (TKA).

Patients and methods

This prospective, case-control study included a total of 43 adult patients (10 males, 33 females; mean age 69 years; range, 50 to 82 years) who were clinically stable and admitted for rehabilitation after fast-track surgery for knee arthroplasty or conventional TKA January 2016 and August 2016. The patients were divided into two groups as the FTR and CR treatment groups. The FTR program was designed as a patient-focused care, early mobilization, and standardized postoperative milestones. The CR program was designed by standard postoperative rehabilitation care. Primary outcomes were the length of stay (LOS) in the hospital and knee function. Secondary outcomes were pain and activities of daily living.

Results

At baseline, both groups were similar in terms of demographic data and primary outcomes. At discharge, intra-group analysis showed significant differences in both groups in all functional outcomes, except for pain, while the inter-group LOS was also significantly different (p<0.001).

Conclusion

Our study results indicate that LOS can be reduced by FTR, yielding the same results in functional recovery and autonomy as CR.

Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

Background

Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods

From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH₃₀) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results

Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH₃₀ of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion

Quality of recovery measured by a median DAH₃₀ of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.

Trial registration

The study was registered with ClinicalTrials.gov (NCT03540667).

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution

BACKGROUND

Outpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD.

METHODS

Five hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients.

RESULTS

One hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001).

CONCLUSION

An option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.

Accelerated rehabilitation versus conventional rehabilitation in total hip arthroplasty (ARTHA): a randomized double blinded clinical trial

OBJECTIVES

compare an accelerated physiotherapeutic protocol to a conventional physiotherapeutic protocol in total hip arthroplasty patients.

METHODS

a randomized double blinded clinical trial performed from August 2013 to November 2014. Forty-eight patients diagnosed with hip osteoarthritis submitted to a total hip arthroplasty surgery. An accelerated rehabilitation physiotherapy applied three times a day and start gait training on the first day or standard physiotherapy applied once a day and start gait training on the second or third day of hospitalization. The Merle dAubigné and Postel score (mobility, pain and gait), muscle strength force, range of motion, in hospital stay and time to start of gait training, were the outcomes.

RESULTS

the mean age was 64.46 years (10.37 years standard deviation). No differences were observed in age in different genders, and the two randomization groups were homogeneous. In hospital stay was lower in the intervention group compared to the control group, 3 (3-4) days [median (interquartile range)] versus 4 (4-5) days. Time to the start of gait training was early in the intervention group compared to the control group, 1 (1-1) days versus 2 (2-2) days. Higher muscle strength values were observed in the postoperative results in the intervention group compared to the control group for internal rotation, external rotation and abduction.

CONCLUSIONS

an accelerated physiotherapeutic protocol should be encouraged, because it shows favourable results in gait, muscle strength and length of hospital stay, even upon hospital discharge.

Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study

PURPOSE

The aim of this study was to evaluate the impact of fast-track procedures (FTPs) on length of hospital stay after primary total knee arthroplasty (TKA) in a prospective, national, multicentric analysis. The innovative point was that no patient selection was used. The hypothesis was that FTPs reduce hospital stay after primary TKA for non-traumatic conditions compared with the national database.

METHODS

An observational prospective study was conducted in ten centres throughout France. A total of 839 patients included in FTPs were followed up for three months. The average LOS, direct return home rate, unscheduled re-admission rate, and re-intervention rate were compared with those in the national database (93,329 TKAs). Knee society and Oxford score were collected.

RESULTS

The mean LOS was 4.4 ± 3.3 days, while the national base LOS was 6.4 ± 3.1 days (p < 0.001). A total of 560 patients (66.7%) were able to return home, compared with 47,617 (49.6%) in the national database (p < 0.001). Thirty-five patients (4.2%) were re-admitted within 90 days of the intervention, compared with 10,399 (10.8%) in the national database (p < 0.001). Seventeen patients (2.0%) were re-operated upon within 90 days after the TKA, compared with 529 (0.5%) in the national database (p < 0.05).

CONCLUSION

The FTPs used by unselected patients allowed a significant decrease in the mean LOS and in the rate of re-admission and a significant increase of the rate of direct home return after primary TKA compared with the national database. The significant increase in the re-operation rate warrants further investigation. However, FTP should become the standard of care after this intervention.

Disadvantage during Perioperative Period of Total Hip Arthroplasty Using the Direct Anterior Approach: a Network Meta-Analysis

BACKGROUND

The purpose of this study was to analyze complications of complete hip arthroplasty through systematic review and network meta-analysis of comparative studies of direct anterior approach (DAA), anterolateral approach (LA), and posterolateral approach (PA).

METHODS

Prospective randomized controlled trials (RCTs) or quasi-experimental designs evaluating clinical outcomes of DAA, LA, and PA for complete hip arthroplasty are valid if they meet the following criteria: 1) Comparison of clinical outcomes between the three methods for main complete hip arthroplasty (total hip arthroplasty, THA); 2) Compared at least one of the following outcomes: blood loss, operating time, and transfusion volume; 3) Sufficient data were available to extract and pool, i.e., mean reported, standard deviation and number of subjects. A network meta-analysis was used to determine the results of treatment across various surgical approaches. Indirect comparisons between the two surgical approaches was made by borrowing details from the standard comparator (i.e., the posterior approach).

RESULTS

Eight prospective RCTs were included in the meta-analysis of the network. The operation time of the LA was longer than that of PA (standardized mean difference [SMD], 0.96; 95% confidence interval [CI], 0.74-1.18; P < 0.001). DAA also had significantly longer operation time than PA (SMD, 0.45; 95% CI, 0.24-0.66; P < 0.001). However, blood loss of the DAA was the highest compared to other approaches (SMD, 0.60; 95% CI, 0.39-0.82; P = 0.002).

CONCLUSION

When performing THA with DAA, we should pay attention to increased operation time and blood loss.

The results of a stepwise implementation of a fast-track program in total hip and knee replacement patients

Background

Several reports have shown that enhanced recovery or fast-track (FT) regime introduction in patients undergoing total knee replacement (TKR) and total hip replacement (THR) results in significant reduction in length of stay (LOS) with no associated increase of complications or readmission rate. Despite that, FT programs for arthroplasty have has not been uniformly recognized or accepted by many orthopaedic surgeons and there is still no consensus on the best implementation process. The aim of this study was to report the results of a stepwise implementation of a FT regime in TKR and THR patients in a general orthopaedic department.

Material and methods

This was a retrospective study of prospectively collected data (from 2014 to 2017) concerning all consecutive unselected patients who underwent TKR or THR on Monday morning. At stage 1 the rehabilitation and physiotherapy component was changed, at stage 2 and 3 a patient's blood management program and a pain management program were prospectively recorded (i.e. respectively Patients' demographics, ASA classification, Charlson index, LOS, blood loss, transfusion rate, complications and 30 - day readmissions).

Results

Four hundred and thirty four patients underwent either TKR (n: 302) or THR (n:132) and were included in this study. A gradual reduction of mean LOS was found in THR patients from 5.7 days to 3.0 days and in TKR patients from 5.6 days to 3.4 days. Furthermore, no significant difference was found in complications or regarding the 30-day readmission rate at the different stages of implementation of the different FT components (i.e. at the final stage 96.7% of THR and 86.7% of TKR patients were discharged to home by the fourth post-operative day).

Conclusion

The stepwise implementation of a FT program in an unelected population of THR and TKR patients was effective and safe, reducing the post-surgical recovery time and patients' LOS with no major complications and no increase of 30-day re-admissions.

Risk Factors for Greater Than 24-Hour Length of Stay After Primary Total Knee Arthroplasty

BACKGROUND

Recently, the Center for Medicare Services removed total knee arthroplasty (TKA) from the inpatient-only procedure list. The purpose of this study is to assess the role of demographics, medical comorbidities, and postsurgical complications in predicting safe discharge to home within 24 hours after TKA.

METHODS

Patients undergoing primary TKA between 2011 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Patients were grouped into those whose length of stay (LOS) was less than 24 hours after surgery vs those greater than 24 hours. Demographics, preoperative comorbidities, operative variables, and postoperative adverse events were studied as risk factors for LOS greater than 24 hours.

RESULTS

A total of 210,075 patients undergoing primary TKA met the inclusion criteria, and of those, 18,134 (8.6%) patients were discharged within 24 hours postoperatively. In a risk-adjusted multivariate analysis, patients with increasing age, obesity, preoperative comorbidities of smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, hypertension, bleeding disorder, corticosteroid use preoperatively, and dependent functional status conferred a greater risk for discharge greater than 24 hours. Male gender, spinal anesthesia, and monitored anesthesia care were protective against LOS greater than 24 hours.

CONCLUSION

This study suggests that dependent functional status, preoperative comorbidities, and postoperative complications are all associated with a LOS greater than 24 hours after TKA. Surgeons and patients should be aware of the clinical and demographic variables associated with risk for LOS greater than 24 hours when considering outpatient status for patients undergoing TKA.

Three and a half years’ experience with outpatient total hip arthroplasty

Aims

The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA).

Methods

In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered.

Results

Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol.

Conclusion

These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82–89

Does performing outpatient total hip arthroplasty contribute to early complications and readmissions? Retrospective case-control study of 50 patients

INTRODUCTION

Advances in anesthesia and surgical practices have allowed total hip arthroplasty to be performed as an outpatient procedure. The aim of this study was to demonstrate its feasibility in a selected population compared to a group of inpatients by analyzing the cumulative length of hospital stay, complications and readmissions.

PATIENTS AND METHODS

This was a retrospective, single-surgeon study of continuous adult patients between October 2016 and May 2018 who underwent primary total hip arthroplasty (THA) and were eligible to undergo this procedure either as an inpatient or outpatient based on their health and comprehension level. Two groups of patients were set up. The outpatient group was given a preoperative treatment education session. The same anesthesia protocol and surgical technique was used in both groups.

RESULTS

Fifty outpatients were compared to 77 inpatients. In the outpatient group, the patients were significantly younger, had a greater walking distance and were predominantly male. The two groups were comparable in terms of functional and medical criteria. The mean cumulative hospital stay was 1.2days in the outpatient group with one discharge failure because of nausea and vomiting, versus 5.1days in the inpatient group (p<0.0001). There were three complications in each group (p=1.00). There were three readmissions in the outpatient group and four in the inpatient group (p=1.00) that were of similar length (p=0.86). There was no difference in the mean number of additional office visits over this period between the two groups.

CONCLUSION

Outpatient THA procedures can be done reliably and safely in France in a carefully selected population without increasing the complication rate or readmission rate. Expanding this practice requires implementing specific anesthesia and surgery protocols, along with close perioperative monitoring to help manage risk.

LEVEL OF EVIDENCE

IV (retrospective cohort study).

Low complication rate after same-day total hip arthroplasty: a retrospective, single-center cohort study in 116 procedures

Background and purpose - Length of hospital stay (LOS) following total hip arthroplasty (THA) has been markedly reduced. Recently, same-day THA (SD-THA) was introduced, and previous studies have indicated satisfactory safety. However, studies are heterogeneous and only a few report results on SD-THA when using a posterolateral surgical approach. Thus, our aim was to evaluate the feasibility of and complications after SD-THA when using a posterolateral approach. Patients and methods - Consecutive patients scheduled for SD-THA between October 2015 and June 2016 were included. Eligibility criteria for SD-THA were: primary THA, motivation for same-day procedure, age > 18 years, ASA I or II, and the presence of a support person who could remain with the patient for 24 hours after surgery. A posterolateral surgical approach was used. Data were collected retrospectively from hospital records and the Danish National Patient Registry. Outcome measures were: complications during admission, LOS, causes of prolonged admission, and prevalence and causes of readmission at 90 days' follow-up. Results - 102 of 116 (88%) patients scheduled for SD-THA were discharged on the day of surgery. The remaining 14 patients were discharged the following day. Primary causes of prolonged admission were: dizziness/nausea, pain, and wound seepage. 7 patients had an estimated blood loss above 400 mL, but all were discharged as planned. No major complications occurred during admission. At follow-up, 3 patients had been readmitted due to pneumonia, wound infection, and dislocation, respectively. Interpretation - The results indicate that SD-THA performed with a posterolateral approach is feasible and can be performed with a low complication rate in a selected group of patients.

[Fast track concepts in total knee arthroplasty: use of tranexamic acid and local intra-articular anesthesia technique]

OBJECTIVE

Fast track concepts are used to reduce the risk of perioperative and postoperative complications after total knee arthroplasty.

INDICATIONS

The described concepts are used for patients with indications for the implantation of a total knee prosthesis.

CONTRAINDICATIONS

Contraindications for fast track concepts are aged patients, dementia, American Society of Anesthesiologists (ASA) grade IV and implantation of large revision or tumor prostheses. Contraindications for tranexamic acid are bleeding in the urinary tract, caution in cases of known epilepsy, individual risk assessment in existing thromboses or increased thrombosis risk, fresh myocardial infarction, conditions following fresh pulmonary embolism, percutaneous transluminal coronary angioplasty (PTCA) and stent implantation. Contraindications for ropivacaine are hypersensitivity (allergy) to ropivacaine and other amide type topical anesthetics and hypovolemia.

SURGICAL TECHNIQUE

Preoperative administration of 1 g tranexamic acid and intraoperative local infiltration anesthesia are carried out. After femoral and tibial bone resection and before cementing the femoral and tibial components, approximately 40 ml of ropivacaine (2%) is injected into the posterior capsule. This is followed by injection of the medial and lateral collateral ligaments with approximately 20 ml each and infiltration of Hoffa's fat pad and the extensor apparatus also with approximately 20 ml local anesthetic. After cementing, the subcutaneous tissue is infiltrated with approximately 50 ml ropivacaine solution.

POSTOPERATIVE MANAGEMENT

On the same day as the operation the patient is mobilized with the help of a physiotherapist. The patient should, if possible, walk a few steps on crutches. Systemic analgesic treatment is carried out according to the World Health Organization (WHO) staged scheme II with a weak opioid and first stage non-opioid analgesic (nonsteroidal anti-inflammatory drug, NSAID and/or metamizole). Gabapentin can be used as an adjuvant comedication. Medicinal thrombosis prophylaxis is carried out with a low molecular weight heparin for 2 weeks postoperatively.

RESULTS

In 100 patients who preoperatively received 1 g tranexamic acid and intra-articular infiltration anesthesia, in the evening of the day of the operation the pain was on average 2.1 (±1.8) on the numeric pain rating scale (NPRS). In one patient, there was a sensitive deficit of the lower leg and foot. A motor deficit was not observed. A total of 90 patients were able to raise and straighten leg. On the day of surgery 68 patients were able to walk more than 10 steps and 22 patients could be mobilized to a standing position. The mean length of hospital stay was 6.6 days (5-11 days). No infections, thromboses or pulmonary embolisms occurred.

Improving the Patient Experience Following Total Knee and Total Hip Arthroplasty: A Practice Development Project

BACKGROUND

The paradigm shift that has occurred for patients with total hip (THA) and knee (TKA) arthroplasty through enhanced recovery programs underscores the need for redesigning care provision.

LOCAL PROBLEM

In this hospital, the patient outcomes and experience anticipated from the implementation of enhanced recovery medical protocols were not fully realized.

METHODS

The Practice Development in Nursing and Healthcare model guided this project.

INTERVENTIONS

A nurse-led team designed a new care delivery model with patient/family-centered interventions based on the best evidence.

RESULTS

Outcomes included an increase in discharges of postoperative day 1 or less of 154% THA and 41.8% TKA and an increase in discharge to home by 24.6% THA and 18.7% TKA. In addition, 90-day readmissions were reduced for both patient groups.

CONCLUSIONS

An interprofessional team of clinicians made sustainable improvements in the experience and outcomes for the surgical patients with THA and TKA.

Impact of early mobilization on length of stay after primary total knee arthroplasty

Background

Decreasing length of stay (LOS) following primary total knee arthroplasty (TKA) has been an important focus by all the stakeholders involved in the delivery of care. LOS is dictated by both the patient and hospital-related factors. The purpose of this study was to determine if early mobilization on post-operative day 0 (POD 0) following primary TKA has an effect on hospital LOS and discharge to home vs. rehabilitation facilities.

Methods

An analysis was performed of consecutive primary TKAs performed at a single institution over one year. Patients were assigned to two groups: POD 0 or POD 1, based on their day of mobilization. Patients were mobilized following surgery based on time of arrival to the orthopaedic floor and availability of physical therapy (PT) resources. The two groups were compared for LOS and discharge disposition using univariate analysis. A total of 408 consecutive TKAs were evaluated and from this group, a total of 143 patients who were mobilized on POD 0 were then matched to 143 patients mobilized on POD 1. There were no significant differences in age, sex, American Society of Anesthesiologists score, or body mass index (BMI) between POD 0 and POD 1 groups.

Results

There was a significant difference in LOS between POD 0 and POD 1 groups, 2.44 vs. 2.80 days (P=0.002). There were also differences in discharge to home vs. rehabilitation, 70.63% of the POD 0 cohort were discharged home compared to 58.74% in POD 1 (P=0.035).

Conclusions

There was a significant reduction in LOS and there were differences in discharge disposition between patients who mobilized on POD 0 vs. POD 1, with more patients mobilized on POD 0 discharged home. Hospitals should work with their total joint arthroplasty programs to mobilize close to 100% of the patients undergoing primary TKA on POD 0 in order to decrease LOS and healthcare expenditure.

Trends of postoperative length of stay in spine surgery over 10 years in Japan based on a prospective multicenter database

OBJECTIVES

To identify factors associated with prolonged length of stay (LOS) in spine surgery, with the goal of establishing details of LOS for multiple diseases and surgical procedures.

PATIENTS AND METHODS

The subjects were patients who underwent spine surgery at 10 facilities in the Nagoya Spine Group from January 2005 to December 2015. Data were collected for patient background, primary spinal pathology, anatomical location of the lesion, and surgical methods. The primary outcome was LOS, which was defined as the calendar days from surgery to hospital discharge.

RESULTS

A total of 10,829 patients (5953 males, 4876 females; age 5-93 years, mean 60.2 ± 28.8 years) were identified in the database. Average follow-up was 61 months (range: 13-120 months). Average LOS was 22.3 ± 21.3 days, and there was a gradual decrease in LOS over the study period. LOS was significantly correlated with age, and prolonged LOS was significantly associated with thoracic spine surgery and significantly longer after surgery with instrumentation. Average LOS was >30 days for intramedullary tumor resection and posterior cervical fusion, but only 10.2 days for microendoscopic discectomy. Reoperation was performed in 210 patients (1.9%) and these patients had a significantly higher average LOS of 43.1 days.

CONCLUSION

These results will assist quality improvement in spine surgery. The identified risk factors for prolonged LOS will also assist in planning of surgery, postoperative care, and discharge, with the goal of reducing health care costs.

Patients' experiences during the first 12 weeks after discharge in fast-track hip and knee arthroplasty - a qualitative study

BACKGROUND

Due to the shortened length of stay in fast-track total hip and knee arthroplasty, patients must at a very early stage following surgery take responsibility for their postoperative care and treatment. It is important to establish if this treatment modality of fast-track is not only cost-effective, but meets patients' expectations and needs.

AIM

To explore the lived experience of patients in fast-track total hip and knee arthroplasty during the first 12 weeks after discharge.

METHODS

A phenomenological-hermeneutic approach was used inspired by Ricoeur's theory of narrative and interpretation. Data were collected through semi-structured interviews with 8 patients 2 and 12 weeks after discharge.

FINDINGS

Through the structural analysis 3 themes emerged: 1) Dealing with transition between hospital and home, 2) Pain and self-management of medication, 3) Challenges in rehabilitation.

CONCLUSION

Patients appreciated only 1 or 2 days in hospital. However, they were not sufficiently involved in the discharge planning. There was a feeling of uncertainty and being left on their own after discharge, which could affect their pain management and recovery at home. There is a need to develop in partnership with each individual patient a post discharge plan of care and rehabilitation to meet their individual needs, preferences and mode of motivation.

Does Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty Facilitate Early Hospital Discharge?

INTRODUCTION

Our study assessed the effect of total intravenous anesthesia (TIVA) with short-acting spinal anesthesia and aggressive day-of-surgery postoperative day 0 physical therapy (POD#0 PT) on hospital length of stay (LOS) in patients who underwent primary total joint arthroplasty.

METHODS

A retrospective chart review compared the hospital LOS of 116 patients who underwent primary total hip arthroplasty and total knee arthroplasty with TIVA and short-acting spinal blockade ("Updated protocol group") with that of the control group of 228 patients who were under standard anesthesia ("Traditional protocol group").

RESULTS

Both total hip arthroplasty and total knee arthroplasty patients in the Updated protocol group had markedly reduced LOS compared with those in the Traditional protocol group (1.5 ± 0.1 days versus 2.4 ± 0.1 days; P < 0.05 and 1.4 ± 0.1 days versus 2.3 ± 0.1 days; P < 0.05). A higher proportion of patients in the Updated protocol group received at least 1 POD#0 PT session compared with those in the Traditional protocol group.

CONCLUSION

Total intravenous anesthesia combined with short-acting spinal anesthetics provided the following benefits for patients who underwent primary total joint arthroplasty: more day-of-surgery PT sessions and earlier discharge by nearly 1 full day.

LEVEL OF EVIDENCE

III.

Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study

To study the clinical effect and safety of two doses of low-dose perioperative dexamethasone on pain and recovery after total knee arthroplasty. Methods A total of 108 patients were included in this randomized, double-blinded, placebo-controlled study. They received two doses of 10 mg IV dexamethasone (group Dexa) or IV isotonic saline (group Placebo). The CRP, IL-6 and pain levels, postoperative nausea and vomiting (PONV) incidence, nausea severity, postoperative fatigue, range of motion, length of stay, analgesic rescue and antiemetic rescue consumption, and complications were compared. Results The CRP and IL-6 levels in group Dexa were lower than in group Placebo at 24, 48, and 72 h postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). In group Dexa, patients had less pain at 24 h postoperatively, at rest (P < 0.001) and during walking (P < 0.001); they also had a lower PONV incidence (P = 0.002) and a lower nausea VAS score (P = 0.008). Postoperative fatigue (P < 0.001) was relieved and the analgesic and antiemetic rescue consumption was reduced. Length of stay (n.s.) and range of motion (n.s.) were similar in both groups. No early surgical wound infection or gastrointestinal haemorrhage occurred in either group. Conclusions Administering two doses of low-dose perioperative dexamethasone for patients receiving total knee arthroplasty reduces postoperative CRP and IL-6 levels, provides additional analgesic effect, and reduces the PONV incidence and postoperative fatigue, without increasing the risk of early surgical wound infection and gastrointestinal haemorrhage. So two doses of low-dose perioperative dexamethasone are effective and safe for patients receiving TKA to decrease the inflammatory response, prevent PONV, relieve postoperative pain and fatigue, and enhance recovery. Level of evidence I.

Reduced length of uninterrupted institutional stay after implementing a fast-track protocol for primary total hip replacement

Background and purpose - Fast-track protocols have been successfully implemented in many hospitals as they have been shown to result in shorter length of stay (LOS) without compromising results. We evaluated the effect of fast-track implementation on the use of institutional care and results after total hip replacement (THR). Patients and methods - 3,193 THRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast-track (Hospital A) and non-fast-track (Hospitals B, C, and D). We analyzed LOS, length of uninterrupted institutional care (LUIC, including LOS), discharge destination, readmission, revision rate, and mortality in each hospital. We compared these outcomes for THRs performed in Hospital A before and after fast-track implementation and we also compared outcomes, excluding readmission rates, with the corresponding outcomes for the other hospitals. Results - After fast-track implementation, median LOS in Hospital A diminished from 5 to 2 days (p < 0.001) and (median) LUIC from 6 to 3 (p = 0.001) days. No statistically significant changes occurred in discharge destination. However, the reduction in LOS was combined with an increase in the 42-day readmission rate (3.1% to 8.3%) (p < 0.001). A higher proportion of patients were at home 1 week after THR (p < 0.001) in Hospital A after fast-tracking than before. Interpretation - The fast-track protocol reduces LUIC but needs careful implementation to maintain good quality of care throughout the treatment process.

Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014

OBJECTIVES

To measure changes in length of stay following total knee and hip replacement (TKR and THR) between 1997 and 2014 and estimate the impact on hospital reimbursement, all else being equal. Further, to assess the degree to which observed trends can be explained by improved efficiency or changes in patient profiles.

DESIGN

Cross-sectional study using routinely collected data.

SETTING

National Health Service primary care records from 1995 to 2014 in the Clinical Practice Research Datalink were linked to hospital inpatient data from 1997 to 2014 in Hospital Episode Statistics Admitted Patient Care.

PARTICIPANTS

Study participants had a diagnosis of osteoarthritis or rheumatoid arthritis.

INTERVENTIONS

Primary TKR, primary THR, revision TKR and revision THR.

PRIMARY OUTCOME MEASURES

Length of stay and hospital reimbursement.

RESULTS

10 260 primary TKR, 10 961 primary THR, 505 revision TKR and 633 revision THR were included. Expected length of stay fell from 16.0 days (95% CI 14.9 to 17.2) in 1997 to 5.4 (5.2 to 5.6) in 2014 for primary TKR and from 14.4 (13.7 to 15.0) to 5.6 (5.4 to 5.8) for primary THR, leading to savings of £1537 and £1412, respectively. Length of stay fell from 29.8 (17.5 to 50.5) to 11.0 (8.3 to 14.6) for revision TKR and from 18.3 (11.6 to 28.9) to 12.5 (9.3 to 16.8) for revision THR, but no significant reduction in reimbursement was estimated. The estimated effect of year of surgery remained similar when patient characteristics were included.

CONCLUSIONS

Length of stay for joint replacement fell substantially from 1997 to 2014. These reductions have translated into substantial savings. While patient characteristics affect length of stay and reimbursement, patient profiles have remained broadly stable over time. The observed reductions appear to be mostly explained by improved efficiency.

Comparison of outcome measures from different pathways following total knee arthroplasty

INTRODUCTION

The benefits of extended inpatient rehabilitation following total knee arthroplasty (TKA) in local community hospitals (CHs) are unproven. Our study compared functional outcomes between patients discharged home and to CHs following TKA.

METHODS

A case-control study was conducted of patients undergoing primary unilateral TKA. Consecutive patients (n = 1,065) were retrospectively reviewed using the Knee Society Clinical Rating System (KSCRS), 36-item Short Form Health Survey (SF-36) and Oxford Knee Score (OKS) preoperatively, and at the six-month and two-year follow-ups.

RESULTS

Overall, 967 (90.8%) patients were discharged home and 98 (9.2%) to CHs. CH patients were older (mean age 70.7 vs. 67.2 years; p < 0.0001), female (86.7% vs. 77.5%; p = 0.0388) and less educated (primary education and above: 61.7% vs. 73.8%; p = 0.0081). Median CH length of stay was 23.0 (range 17.0-32.0) days. Significant predictors of discharge destination were older age, female gender, lower education, and poorer ambulatory status and physical health. Preoperatively, CH patients had worse KSCRS Function (49.2 ± 19.5 vs. 54.4 ± 16.8; p = 0.0201), SF-36 Physical Functioning (34.3 ± 22.6 vs. 40.4 ± 22.2; p = 0.0017) and Social Functioning (48.2 ± 35.1 vs. 56.0 ± 35.6; p = 0.0447) scores. CH patients had less improvement for all scores at all follow-ups. Regardless of preoperative confounders, with repeated analysis of variance, discharge destination was significantly associated with KSCRS, SF-36 and OKS scores.

CONCLUSION

Older, female and less educated patients with poorer preoperative functional scores were more likely to be discharged to CHs after TKA. At the two-year follow-up, patients in CHs had less improvement in functional outcomes than those discharged home.

Minimally invasive unicompartmental knee arthroplasty

The exact indication for a unicompartmental knee arthroplasty (UKA) remains debated. Minimally invasive techniques have been developed to decrease the surgical trauma related to the prosthesis implantation, and this technique is well fitted to UKA. However, there are concerns about loss of accuracy with minimally invasive techniques. Furthermore, rapid recovery techniques have been developed in order to reduce the length of hospital stay. Again, UKA is well fitted to these new developments of postoperative care. We combine routinely a minimal invasive operative technique with navigation assistance to ensure proper positioning of the implants as well as an optimal ligamentous balance. Instruments have been adapted for use with a typical 6-cm skin incision with little change from the conventional navigated operating technique. A multimodal pain treatment is implemented immediately after the implantation, with special attention to a routine saphenous nerve blockade. Patients are instructed to stand up on the day of surgery with full weight bearing and to mobilize the knee joint without restriction. They may be discharged at least on the day following surgery, and the most favorable patients may be operated in our day-case surgery unit. These conclusions should be confirmed on a larger scale.