Economic analyses of fast-track total hip and knee arthroplasty: a systematic review

Trends and Themes in the Study of Value in Orthopedic Surgery: A Systematic Review

Background

The study of value in orthopedic surgery aims to maximize health outcomes gained per unit cost through various health economic tools but is fragmented across various subspecialties and geographies. Therefore, it is difficult to ascertain whether this research methodology is being used to its full potential across all orthopedic subspecialties and geographies.

Purpose

We sought to assess the distribution of prior health economics literature in orthopedic surgery across subspecialties and geographies. The secondary aim was to identify pertinent methodologic trends that may affect the conclusions drawn.

Methods

A systematic review utilizing 3 electronic databases (Medline, Embase, and Web of Science) was performed. Inclusion criteria included prior systematic reviews assessing economic analyses across all orthopedic surgery subspecialities published between 2010 and April 24, 2021. The quality of evidence was assessed using the Assessment of Multiple Systematic Review tool. Data were qualitatively analyzed.

Results

In the 44 studies included, arthroplasty (36.4%) and spine (31.8%) were the most represented subspecialties. Almost half of studies originated from the United States (45.5%), followed by the United Kingdom (18.2%). Health economic models were most commonly from the perspective of the health care or hospital system (40.5%), followed by the societal perspective (23.5%), and the payer perspective (14.8%).

Conclusions

The study of value in orthopedic surgery is not uniformly leveraged across all subspecialties and geographies. Methodologically, the societal perspective was inadequately represented, despite orthopedic pathologies often incurring significant indirect costs (eg, time off work, rehabilitation expenses).

Complication rates are not higher after outpatient compared to inpatient fast-track total hip arthroplasty: a propensity-matched prospective comparative study

PURPOSE

Concerns remain with regards to safety of fast-track (FT) and especially outpatient procedures. The purpose of this study was to compare complication rates and clinical outcomes of propensity-matched patients who received FT total hip arthroplasty (THA) in outpatient versus inpatient settings. The hypothesis was that 90-day postoperative complication rates of outpatient FT THA would not be higher than after inpatient FT THA.

METHODS

This is a prospective study of consecutive patients who received FT THA at various rates of outpatient and inpatient surgery by 10 senior surgeons (10 centres). The decision between outpatient and inpatient surgery was made on a case-by-case basis depending on the surgeon and patient. All patients were followed until 90 days after surgery. Complications, readmissions and reoperations were collected, and their severity was assessed according to Clavien-Dindo. Patients completed Oxford Hip Score (OHS) at the latest follow-up.

RESULTS

Compared to inpatient FT THA, patients scheduled for outpatient FT THA had no significant differences in 90-day postoperative complication rates (10.7% vs. 12.9%, p = 0.129). There were no significant differences between the 2 groups in 90-day readmission rates and reoperation rates, in severity of postoperative complications, and in time of occurrence of postoperative complications.

CONCLUSIONS

There were no differences in rates of intraoperative complications, 90-day postoperative complications, readmissions, or reoperations between outpatient and inpatient FT THA. These findings may help hesitant surgeons to move towards outpatient THA pathways as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

Are Routine Postoperative Hemoglobin Tests Justified in All Patients Who Undergo Total Hip Arthroplasty Due to a Displaced Femoral Neck Fracture?

Background: Total hip arthroplasty (THA) is a standard treatment for a displaced femoral neck fracture in the elderly. In contemporary healthcare, there is a global shift towards fast-track treatment modalities, prioritizing early hospital discharge for patients. Consequently, routine postoperative blood tests may become redundant, offering significant time and cost savings. We aim to evaluate postoperative hemoglobin levels in trauma-related THA cases and identify patient profiles for whom these tests hold significance. Methods: A retrospective review of 176 THA procedures performed between 2018 and 2022, focusing on individuals undergoing THA for displaced femoral neck fractures. Multivariable logistic regression analysis was employed to identify factors associated with postoperative hemoglobin levels below 8.5 g/dL. Results: Of the 176 patients included, 109 (61.9%) were women and the mean age was 69.09 ± 8.13 (range 27 to 90) years. The majority of the patients underwent surgery within 48 hours of admission. The mean preoperative hemoglobin (Hb) level was 13.1 ± 1.4 g/dL, while the mean postoperative Hb level was 10.5 ± 1.2 g/dL. Only six patients (3.41%) exhibited postoperative Hb levels of ≤8.5 g/dL. No significant associations were found between postoperative Hb levels ≤ 8.5 and any demographic, surgical, or medical characteristics. Conclusions: Our findings suggest that routine postoperative blood count testing may not be necessary for most patients undergoing THA for displaced femoral neck fractures, particularly those without complications or significant comorbidities.

Are patients ready for discharge from the hospital after fast-track total knee arthroplasty?-A qualitative study

BACKGROUND

The fast-track based on evidence-based medicine, has dramatically reduced the length of stay for patients undergoing total knee arthroplasty (TKA). Therefore, patients must assume the responsibility for self-functional exercise and care as early as possible. Also, higher standards and expectations of care delivery have been set. Studies into patients' experiences when faced with a discharge decision under a fast-track program are lacking.

OBJECTIVES

(1) Increase the knowledge about patients' experiences of discharged from hospital via a fast-track process after TKA. (2) Explore what gaps exist in the current discharge preparation care service for TKA under fast-track and what can be improved.

METHODS

A qualitative research design was chosen to conduct semi-structured face-to-face interviews with 21 patients from one Chinese hospital who successfully underwent TKA and received discharge orders. Interview data were meticulously analyzed, summarized and thematically distilled using Interpretative Phenomenological Analysis (IPA).

RESULTS

Three themes emerged from the structural analyses: a) Preparing for discharge despite concerns about symptoms-a sense of joy at discharge despite feelings of helplessness, stigmatisation, anxiety about prosthetic function. b) Managing the rehabilitation difficulties-vigilance is needed for medication management, environmental changes, and intimate relationships. c) Creating conditions for safe transition-compassionate bedside manner, listening to patients, and providing a humanized continuing care and referral services are important for safe transitions.

CONCLUSION

Findings suggest that patients undergoing fast-track TKA report good discharge preparation experiences. However, closer analysis reveals difficulties with this process and important directions in which discharge readiness care services can strive.

Simultaneous bilateral TKA in the context of fast track surgery - Do patients meet discharge criteria as anticipated?

BACKGROUND

The efficacy and safety of enhanced recovery after surgery (ERAS) protocols for patients undergoing total knee arthroplasty (TKA) have been generally proven. Previous studies investigating patients undergoing simultaneous bilateral TKA (SBTKA) focused on complications, mortality, and pain and did not examine patients' functional limitations. Therefore, the aim of this study was to investigate to what extent patients undergoing SBTKA are able to meet functional discharge criteria originally designed for their counterparts undergoing unilateral TKA (UTKA) in an ERAS setting.

MATERIALS AND METHODS

All patients who received primary SBTKA between June 2015 and December 2018 were included in this retrospective analysis. For comparison, UTKA patients were matched 1:1 to SBTKA patients using Propensity Score Matching based on age, gender, and BMI. The times to achieving the rehabilitation checkpoints of walking 150 m, walking a flight of stairs, and 90° knee flexion were evaluated.

RESULTS

63 (SBTKA group) and 64 (UTKA group) patients were included. Due to the Propensity-Score-Matching there were no differences regarding age, gender, and BMI. The mean length of stay (LOS) was 9.1 days in the SBTKA and 7.6 days in the UTKA group (p = 0.003). On average, it took SBTKA patients 5.4 days to achieve an uninterrupted walking distance of at least 150 m, while it took UTKA patients 4.1 days (p < 0.001). Mean time to walking a flight of stairs was 6.3 days for SBTKA patients and 4.7 days for UTKA patients (p < 0.001). 90° flexion was achieved after 4.1 days by SBTKA patients and 3.5 days by UTKA patients (p = 0.241).

CONCLUSION

The vast majority of SBTKA patients were able to achieve functional discharge criteria within their inpatient stay when allowed about 30% extra time. Therefore, functional discharge criteria in ERAS protocols designed for UTKA can be considered appropriate for SBTKA patients.

LEVEL OF EVIDENCE

Therapeutic Level III.

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.

The Joint Awareness Score: A Shortened, Simplified, Improved Alternative to the Forgotten Joint Score

Background

The Forgotten Joint Score (FJS) is a 12-question patient-reported outcomes measure created to measure a patient's awareness of their artificial joint. The FJS has attained wide usage, though it is not without weaknesses. Our patients report that the semantics of the English translation are flawed and that the 5 answer options for each question are poorly differentiated. Additionally, the FJS will result in no score if 3 or more questions are unanswered. This prompted the development of an alternative patient-reported outcomes measure, the Joint Awareness Score (JAS), that builds upon the core concept of joint awareness underlying the FJS, but that is easier to understand and shorter to complete. We completed an exploratory, pilot study to evaluate this outcomes instrument. Our hypothesis is that the JAS will correlate strongly with the FJS and could be used as a substitute.

Methods

Knee arthroplasty patients in a prospective registry were administered the FJS and the JAS. Internal consistency and correlation were calculated with Cronbach's alpha and Pearson's correlation coefficient, respectively.

Results

This study included 174 patients. Cronbach's alpha for FJS was 0.97 for 6 months and 0.97 for 12 months, whereas JAS was 0.89 at 6 months and 0.85 at 12 months. Pearson correlation comparing FJS and JAS at 6 months was 0.88 (95% confidence interval: 0.83, 0.92) and 0.86 (95% confidence interval: 0.78, 0.92) at 12 months.

Conclusions

The Joint Awareness Score is a new patient-reported outcomes measure that is a substitute for the FJS, with half the number of questions, improved semantics, and simplified answers.

Quick Transition to One Day Length of Stay after Hip and Knee Arthroplasty Using a Digital Follow-Up Tool during COVID-19: A Retrospective Comparative Study

The COVID-19 pandemic highlighted the need for efficient use of hospital infrastructure. The hypothesis was that a rapid shift to outpatient surgery after hip or knee arthroplasty could be implemented without compromising quality of care. The aim of this study was to assess the safety, pain management and patient-reported outcomes before and after the implementation of an accelerated discharge program using a digital follow-up tool. A retrospective cohort design was used to compare 97 patients who received primary total hip or knee arthroplasty during the pandemic (early discharge) to comparable 194 pre-pandemic patients (normal discharge). Both cohorts had the same inclusion criteria and were closely monitored using the digital follow-up tool. The accelerated discharge program reduced length of stay from a median of 3 days (before the pandemic) to a median of 1 day (during the pandemic) (p < 0.001). The complication rate of 2% was the same for both groups (p > 0.05). Patient-reported outcomes for matched samples of hip (n = 100) and knee (n = 82) arthroplasty patients were similar before, at 6 weeks and 3 months after surgery for both groups (p > 0.05). There were no differences in pain and medication consumption for the first 6 weeks (p > 0.05). This study demonstrates that reducing length of stay from three to one night after total knee or hip arthroplasty, with the help of a digital follow-up tool, results in a stable rate of complications, readmission, and comparable clinical outcomes, while reducing the socio-economic burden on the health system.

Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2)

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life.

Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2)

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life.

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.

The Arthroplasty Surgeon Growth Indicator: A Tool for Monitoring Supply and Demand Trends in the Orthopaedic Surgeon Workforce from 2020 to 2050

BACKGROUND

Orthopaedic practices in the U.S. face a growing demand for total joint arthroplasties (TJAs), while the orthopaedic workforce size has been stagnant for decades. This study aimed to estimate annual TJA demand and orthopaedic surgeon workforce supply from 2020 to 2050, and to develop an arthroplasty surgeon growth indicator (ASGI), based on the arthroplasty-to-surgeon ratio (ASR), to gauge nationwide supply and demand trends.

METHODS

National Inpatient Sample and Association of American Medical Colleges data were reviewed for individuals who underwent primary TJA and for active orthopaedic surgeons (2010 to 2020), respectively. The projected annual TJA volume and number of orthopaedic surgeons were modeled using negative binominal and linear regression, respectively. The ASR is the number of actual (or projected) annual total hip (THA) and/or knee (TKA) arthroplasties divided by the number of actual (or projected) orthopaedic surgeons. ASGI values were calculated using the 2017 ASR values as the reference, with the resulting 2017 ASGI defined as 100.

RESULTS

The ASR calculation for 2017 showed an annual caseload per orthopaedic surgeon (n = 19,001) of 24.1 THAs, 41.1 TKAs, and 65.2 TJAs. By 2050, the TJA volume was projected to be 1,219,852 THAs (95% confidence interval [CI]: 464,808 to 3,201,804) and 1,037,474 TKAs (95% CI: 575,589 to 1,870,037). The number of orthopaedic surgeons was projected to decrease by 14% from 2020 to 2050 (18,834 [95% CI: 18,573 to 19,095] to 16,189 [95% CI: 14,724 to 17,655]). This would yield ASRs of 75.4 THAs (95% CI: 31.6 to 181.4), 64.1 TKAs (95% CI: 39.1 to 105.9), and 139.4 TJAs (95% CI: 70.7 to 287.3) by 2050. The TJA ASGI would double from 100 in 2017 to 213.9 (95% CI: 108.4 to 440.7) in 2050.

CONCLUSIONS

Based on historical trends in TJA volumes and active orthopaedic surgeons, the average TJA caseload per orthopaedic surgeon may need to double by 2050 to meet projected U.S. demand. Further studies are needed to determine how the workforce can best meet this demand without compromising the quality of care in a value-driven health-care model. However, increasing the number of trained orthopaedic surgeons by 10% every 5 years may be a potential solution.

[Knee flexion after hospitalisation is no predictor for functional outcome one year after total knee arthroplasty]

OBJECTIVE

In total knee arthroplasty (TKA), range of motion has become established as an important factor. The criterion of quality is set to flexion of 90° after hospitalisation. Currently, it is supposed to be a predictor for 1‑year postoperative outcome. However, as this correlation has not been proven, this clinical trial was performed.

METHODS

A total of 182 TKA recipients were analysed retrospectively. Outcomes were assessed before surgery, after hospitalization, 6 weeks and 1 year post surgery. They included knee range of motion (ROM) to answer the main hypothesis, but also KSS, SF-36, WOMAC, EQ-5D and VAS to evaluate knee function and quality of life. The patients were divided into two groups differing in achieving 90° flexion after hospitalisation and compared 6 weeks and 1 year after surgery.

RESULTS

Knee flexion differed significantly between groups from 91 to 70° in the group without the aim of 90° flexion after hospitalisation (E) (p < 0.001). After 6 weeks, flexion was improved to 112° ± 13° (E > 90°) vs. 106° ± 14° (E < 90°; p = 0.001). One year post surgery, knee flexion averaged 122° ± 10° (E > 90°) vs. 120° ± 10° (E < 90°) with no difference between the groups (p = 0.57) and no significant difference in all other scores concerning knee function and quality of life.

CONCLUSION

Flexion of 90° after hospitalisation is not adequate to predict medium-term outcomes after TKA. There is no advantage or disadvantage regarding whether the aim of 90° flexion is achieved.

Fast-track surgery and telerehabilitation protocol in unicompartmental knee arthroplasty leads to superior outcomes when compared with the standard protocol: a propensity-matched pilot study

BACKGROUND

Several strategies have been devised to reduce the length of stay after orthopedic surgery. Telerehabilitation has proved effective in functional outcomes after orthopedic procedures and is appreciated by patients. There is limited information on fast-track surgery and telerehabilitation protocols for unicompartmental knee arthroplasty (UKA). The purpose of this pilot study was to report and compare functional outcomes and satisfaction levels during first 12 months of recovery in patients who underwent UKA according to a fast-track and telerehabilitation protocol (G1) or standard surgery and rehabilitation program (G2).

METHODS

Data were retrospectively collected and reviewed for all elective UKAs from January 2018 to November 2019. A total of seven patients undergoing UKA according to the fast-track and telerehabilitation protocol were propensity score matched (1:3 ratio) to 21 patients undergoing standard surgery and rehabilitation. Patients were matched for age, sex, body mass index (BMI), and laterality. The Western Ontario and McMaster University (WOMAC) osteoarthritis index and range of motion (ROM) were collected pre- and postoperatively in both groups for 12 months. In addition, patient' satisfaction was collected at 40 days.

RESULTS

The G1 group demonstrated significantly better outcomes in WOMAC index scores at 2, 15, and 40 days (p < 0.001, p < 0.001, p < 0.020, respectively) and a significantly greater knee ROM after surgery and at 2, 15, 40, and 12 months (p < 0.001, p < 0.001, p = 0.014, p < 0.001, p = 0.003, respectively). No patients in either group had postoperative complications. One patient was not completely satisfied in the G2, while no one in G1 reported not being completely satisfied (p = 1.000).

CONCLUSIONS

This fast-track and telerehabilitation protocol after UKA can potentially be applied to patients as it is safe and effective. At 12-months follow-up, both groups reported favorable outcomes after UKA. However, the G1 score was better regarding WOMAC and ROM when compared with the propensity score-matched G2 program. A larger study is warranted to explore the role of fast-track and telerehabilitation in clinical and functional outcomes of UKA.

Readmissions and mortality after outpatient vs inpatient unicompartmental knee arthroplasty in Denmark - A propensity score matched study of 5,384 procedures

BACKGROUND

Limited nationwide data on the development of outpatient unicompartmental knee arthroplasty (UKA) practice and patient safety exist. The primary objective of this study on patients receiving a medial or lateral UKA was to investigate 7-, 30- and 90-day readmission risk and 90-day mortality in outpatient vs inpatient surgeries. Secondary to investigate the nationwide development of outpatient UKA surgery in 2014-2018.

METHODS

Included patients received a medial or lateral UKA in the period January 1, 2014 to December 31, 2018 in any Danish hospital. Data were collected from the Danish National Patient Register. The cohort consisted of 1,059 outpatient and 4,325 inpatient surgeries, hereof 5,182 medial and 202 lateral UKA. After propensity score matching (1:1) 1,057 patients were included in each group.

RESULTS

We found a 7-day readmission risk of 1.5 % vs 1.4 % (p = 0.8), 30-day readmission risk of 2.6 % vs 3.2 % (p = 0.3), and 90-day readmission risk of 4.2 % vs 4.8 % (p = 0.4) after outpatient vs inpatient UKA. Similar results were found after matching. We found no significant differences in 90-day mortality for the unmatched or matched cohorts. The amount of outpatient UKA surgeries in Denmark increased from 86 in 2014 to 214 in 2018.

CONCLUSION

Outpatient medial or lateral UKA seem to be as safe as inpatient UKA on a nationwide basis.

Same-day discharge to home is feasible and safe in up to 75% of unselected total hip and knee arthroplasty

PURPOSE

Though numerous studies highlighted benefits of ambulatory total joint arthroplasty (TJA), most had selected patients with age and comorbidities thresholds. We aimed to report proportions of unselected TJAs that could be scheduled for and operated in ambulatory settings, and to determine factors that hinder same-day discharge (SDD).

METHODS

We studied 1100 consecutive primary TJAs (644 THAs and 456 TKAs) that were prepared following a multidisciplinary protocol for patient education and logistical preparation. Data were stratified for THA vs TKA and for success vs failure of SDD to home and multivariable analysis was performed to determine factors associated with failure of scheduled SDD to home.

RESULTS

In total, 860 (78.2%) were scheduled for ambulatory surgery, but only 819 (74.5%) achieved SDD to home; 240 (21.8%) were scheduled for non-ambulatory surgery, but 103 (9.3%) achieved SDD to rehabilitation centre. Re-operations were required in 9 (1.0%) ambulatory TJAs vs 2 (0.8%) non-ambulatory TJAs (p = 0.769), while revisions were required in 13 (1.5%) ambulatory TJAs vs 1 (0.4%) non-ambulatory TJAs (p = 0.181). Multivariable analysis confirmed that failure of SDD to home was greater for women (OR 2.59; p = 0.011) and THA (vs TKA, OR 2.41; p = 0.023).

CONCLUSION

With appropriate education and preparation, 75% of unselected primary hip and knee arthroplasties achieved SDD to home without compromising risks of complications, re-operations, or revisions. A further 9% achieved SDD to rehabilitation centre, implying that 84% of patients did not require overnight stay. These findings suggest that ambulatory surgery is feasible and safe to implement in most unselected lower limb arthroplasties.

Comparing ERAS-outpatient versus standard-inpatient hip and knee replacements: a mixed methods study exploring the experience of patients who underwent both

BACKGROUND

Optimizing patients' total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs.

METHODS

We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients' characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together.

RESULTS

The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients' THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36-0.66], p-value < 0.01).

CONCLUSION

Whatever the perioperative program, the key to improving patients' THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients' experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients' THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

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.

Biosensors for Detection and Monitoring of Joint Infections

The aim of this review is to assess the use of biosensors in the diagnosis and monitoring of joint infection (JI). JI is worldwide considered a significant cause of morbidity and mortality in developed countries. Due to the progressive ageing of the global population, the request for joint replacement increases, with a significant rise in the risk of periprosthetic joint infection (PJI). Nowadays, the diagnosis of JI is based on clinical and radiological findings. Nuclear imaging studies are an option but are not cost-effective. Serum inflammatory markers and the analysis of the aspirated synovial fluid are required to confirm the diagnosis. However, a quick and accurate diagnosis of JI may remain elusive as no rapid and highly accurate diagnostic method was validated. A comprehensive search on Medline, EMBASE, Scopus, CINAH, CENTRAL, Google Scholar, and Web of Science was conducted from the inception to June 2021. The PRISMA guidelines were used to improve the reporting of the review. The MINORS was used for quality assessment. From a total of 155 studies identified, only four articles were eligible for this study. The main advantages of biosensors reported were accuracy and capability to detect bacteria also in negative culture cases. Otherwise, due to the few studies and the low level of evidence of the papers included, it was impossible to find significant results. Therefore, further high-quality studies are required.

Implementing fast-track in total hip arthroplasty: rapid mobilization with low need for pain medication and low pain values : Retrospective analysis of 102 consecutive patients

Introduction

Total hip arthroplasty (THA) is reported to be one of the most painful surgical procedures. Perioperative management and rehabilitation patterns are of great importance for the success of the procedure. The aim of this cohort study was the evaluation of function, mobilization and pain scores during the inpatient stay (6 days postoperatively) and 4 weeks after fast-track THA.

Materials and methods

A total of 102 consecutive patients were included in this retrospective cohort trial after minimally invasive cementless total hip arthroplasty under spinal anesthesia in a fast-track setup. The extent of mobilization under full-weight-bearing with crutches (walking distance in meters and necessity of nurse aid) and pain values using a numerical rating scale (NRS) were measured. Function was evaluated measuring the range of motion (ROM) and the ability of sitting on a chair, walking and personal hygiene. Furthermore, circumferences of thighs were measured to evaluate the extent of postoperative swelling. The widespread Harris Hip Score (HHS) was used to compare results pre- and 4 weeks postoperatively.

Results

Evaluation of pain scores in the postoperative course showed a constant decrease in the first postoperative week (days 1–6 postoperatively). The pain scores before surgery were significantly higher than surgery (day 6), during mobilization (p < 0.001), at rest (p < 0.001) and at night (p < 0.001). All patients were able to mobilize on the day of surgery. In addition, there was a significant improvement in independent activities within the first 6 days postoperatively: sitting on a chair (p < 0.001), walking (p < 0.001) and personal hygiene (p < 0.001). There was no significant difference between the measured preoperative and postoperative (day 6 after surgery) thigh circumferences above the knee joint. Compared to preoperatively, there was a significant (p < 0.001) improvement of the HHS 4 weeks after surgery. In 100% of the cases, the operation was reported to be successful and all of the treated patients would choose a fast-track setup again.

Conclusion

Application of a fast-track scheme is effective regarding function and mobilization of patients. Low pain values and rapid improvement of walking distance confirms the success of the fast-track concept in the immediate postoperative course. Future prospective studies have to confirm the results comparing a conventional and a fast-track pathway.

Total Hip Arthroplasty: Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Forgotten Joint Score 12

The Forgotten Joint Score-12 (FJS-12) is a valid patient-reported outcome measures (PROMs) used to assess prosthesis awareness during daily activities after total hip arthroplasty (THA). The minimum clinically important difference (MCID) can be defined as the smallest change or difference that is evaluated as beneficial and could change the patient’s clinical management. The patient acceptable symptom state (PASS) is considered the minimum PROMs cut-off value that corresponds to a patient’s satisfactory state of health. Despite the validity and reliability of the FJS-12 having been already demonstrated, the MCID and the PASS of this score have not previously been defined. Patients undergoing THA from January 2019 to October 2019 were assessed pre-operatively and six months post-surgery using the FJS-12, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Oxford Hip Score (OHS). Pre-operative and follow-up questionnaires were completed by 50 patients. Both distribution-based approaches and anchor approaches were used to estimate MCID. The aim of this paper was to assess the MCID and PASS values of FJS-12 after total hip replacement. The FJS-12 MCID from baseline to 6 months post-operative follow-up was 17.5. The PASS calculated ranged from 69.8 to 91.7.

The Pertinent Literature of Enhanced Recovery after Surgery Programs: A Bibliometric Approach

Background and Objectives: The programs of enhanced recovery after surgery are the new revolution in surgical departments; however, features of this concept have not been systematically explored. Therefore, the purpose of this study was to explore Enhanced recovery after surgery (ERAS)-related research using bibliometric analysis. Materials and Methods: The search strategy of ERAS programs was conducted in the Web of Science database. Bibliometric analysis was further performed by Excel and Bibliometrix software. The relationship between citation counts and Mendeley readers was assessed by linear regression analysis. Results: 8539 studies from 1994-2019 were included in the present research, with reporting studies originating from 91 countries using 18 languages. The United States (US) published the greatest number of articles. International cooperation was discovered in 82 countries, with the most cooperative country being the United Kingdom. Henrik Kehlet was found to have published the highest number of studies. The journal Anesthesia and Analgesia had the largest number of articles. Linear regression analysis presented a strong positive correlation between citations and Mendeley readers. Most research was related to gastrointestinal surgery in this field. Conclusion: This bibliometric analysis shows the current status of ERAS programs from multiple perspectives, and it provides reference and guidance to scholars for further research.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]

INTRODUCTION

Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment.

METHODS

Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment.

RESULTS

The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions.

CONCLUSION

Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.

Unicompartmental knee arthroplasty undertaken using a fast-track protocol

Aims

The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA.

Methods

We included data from eight dedicated fast-track centres, all reporting UKAs to the same database, between 2010 and 2018. Complete ( > 99%) data on length of stay, 90-day readmission, and mortality were obtained during the study period. Specific reasons for a length of stay of > two days, length of stay > four days, and 30- and 90-day readmission were recorded. The use of UKA in the different centres was dichotomized into ≥ 20% versus < 20% of arthroplasties which were undertaken being UKAs, and ≥ 52 UKAs versus < 52 UKAs being undertaken annually.

Results

A total of 3,927 procedures were included. Length of stay (mean 1.1 days (SD 1.1), median 1 (IQR 0 to 1)) was unchanged during the study period. The proportion of procedures with a length of stay > two days was also largely unchanged during this time. The percentage of patients discharged on the day of surgery varied greatly between centres (0% to 50% (0 to 481)), with centres with high UKA utilization (both usage and volume) having a larger proportion of same-day discharges. The 30- and 90-day readmissions were 166 (4.2%) and 272 (6.9%), respectively; the 90-day mortality was 0.08% (n = 3).

Conclusion

Our findings suggest general underutilization of the potential for quicker recovery following UKA in a fast-track setup. Cite this article: Bone Joint J 2020;102-B(9):1167–1175.

Perioperative Pain Management in Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand?

Total Hip replacement (THR) is a well-discussed topic, and it offers excellent results in patients suffering from end-stage osteoarthritis (OA). However, despite the fact that patients can fully bear weight immediately after the surgery, THR is often associated with a great amount of postoperative pain affecting recovery and rehabilitation. Therefore, the efficient management of pain is of paramount importance. The aim of this review is to examine all the currently available strategies of pain management such as preemptive analgesia (PA), patient-controlled analgesia (PCA), and the various types of anesthesia that are used during the operation. With that objective in mind, we conducted our research by searching through the PubMed database for articles published in 2015 and after. For purely clinical reasons, we have attempted to classify all the best available evidence into three major categories: prior to surgery, during the surgery, and after the surgery. Multimodal analgesia seems to play a major role in the perioperative care of patients undergoing total hip arthroplasty (THA). Therefore, a considerable number of studies have been conducted analyzing all the current strategies that aim to minimize perioperative pain and consequent complications.

Reflections from London's Level-1 Major Trauma Centres during the COVID crisis

Emergence of the Covid-19 pandemic resulted in dramatic changes in global healthcare provision. Resources were redirected across all healthcare sectors to support the treatment of viral pneumonia with resultant effects on other essential services. We describe the impact of this on the provision of major trauma care in a major capital city.

['Hip-in-a-Day']

BACKGROUND

In 2017, the average length of stay for primary hip replacement patients in Germany was 10.2 days. In our hospital, we have been able to reduce the length of stay in the last 10 years to an average of 3.8 days.

OBJECTIVES

Since September 2015, we offer the 'Hip-in-a-Day' program. This ultra-fast-track pathway consists of a hip arthroplasty procedure with the same day discharge of a well-prepared and explicitly selected patient with maximum intensive interdisciplinary care. The aim is to present the philosophy, treatment principles and daily routine during the pre-, intra- and postoperative phase. The challenges in the German health care system will be discussed.

MATERIAL AND METHODS

From September 2015 to November 2019, we operated on 97 patients (50 F: 47 M, ages: 43-77 years, ⌀ 55 years) who had undergone the Hip-in-a-Day pathway. All 97 patients received general anesthesia. Surgery was performed via the direct anterior approach (DAA) to the hip. Patients stayed in the day clinic less than 24 h after surgery. Of these, 30 patients were discharged on the day of surgery (⌀ 12 h stay), and 67 patients left the clinic the day after the operation (⌀ 20 h stay). Due to integrated health-care contracts with health-care providers, we were eligible to receive bundled reimbursement for this patient population.

RESULTS

All 97 patients completed the Ultra-Fast-Track pathway and were able to meet the discharge criteria within 24 h after surgery. 96 of the 97 (98.9%) patients were able to complete Hip-in-a-Day without readmission. One patient had to undergo revision surgery after 10 days due to cup loosening. All patients (100%) were very satisfied with the routine of the day and the fast discharge from the hospital.

CONCLUSION

The aim of Hip-in-a-Day is to discharge patients within 24 h after surgery. The implementation of the setup at the day clinic is intensive interdisciplinary care of all participating departments, as well as the three cornerstones of anesthesiological management, minimally invasive surgical techniques and patient compliance. In our clinic, ultra-fast-track arthroplasty is routinely feasible and has produced great patient satisfaction. Statutory health-care providers should include short-stay hip arthroplasty into the DRG system, so that this care concept can be reimbursed and practiced nationwide in Germany.

[Challenges of fast-track arthroplasty in Germany]

BACKGROUND

While fast-track arthroplasty has been already established in many European countries and the United States, Germany still struggles to introduce appropriate programs. This is due to a variety of reasons.

REASONS

From an organizational and medical scope, the fear of alteration, the adherence to restrictions rooted in historical tradition, the reluctance to interdisciplinary cooperation, and the lack of a willingness to implement externally-guided process analysis tools, stand in the foreground. This is system related, and especially the DRG-system with the continuous devaluation of lump compensation rates in primary hip and knee arthroplasty, also in 2020, hinders the implementation. The resulting fears and concerns that an additional reduction of the length-of-stay by fast-track programs is leading to a consistent reduction of the DRG returns, are understandable. On the other hand, the disconnectedness of the ambulatory, inpatient and rehabilitation sector in Germany inhibits the introduction of fast-track programs.

SOLUTIONS

A well-thought-out change-management is the basic requirement for the successfull establishment of a Fast-Track-Program. Perspectively, a rethinking towards sector-comprehensive care strategies for the implantation of a total hip or knee replacement, including the required rehabilitation procedures, has to be demanded.