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Song K, Qi L, Mu Z, Sun H, Zhai S, Liu D, Li S, Luo Y, Liu P. Health-related quality of life after total knee arthroplasty and unicompartmental knee arthroplasty for unicompartmental osteoarthritis: A systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2024; 32:10225536241256245. [PMID: 38763777 DOI: 10.1177/10225536241256245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND While previous research has demonstrated potential advantages of unicompartmental knee arthroplasty (UKA) over total knee arthroplasty (TKA), particularly in terms of clinical outcomes such as function and pain relief, the specific impact on health-related quality of life (HRQOL) remains unclear. This systematic review and meta-analysis aim to address this gap by comparing HRQOL outcomes between UKA and TKA, providing valuable insights for clinical decision-making. METHODS We conducted a literature search in the PubMed, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Web of Science databases up to July 15, 2023. Eligible studies assessed HRQOL using EQ-5D, SF-36, or SF-12 and were assessed for methodological quality using the Newcastle-Ottawa Scale (NOS). RESULTS Seven eligible studies were included, comprising a total of 64,585 patients with 35,809 undergoing TKA and 28,776 undergoing UKA. Patient age ranged from 52.0 to 67.7 years with an average BMI ranging from 27.2 to 31.0 kg/m2. Follow-up periods ranged from 6 months to 10 years. Five studies (63,829 patients) that evaluated HRQOL using EQ-5D showed significantly better outcomes for UKA compared to TKA (MD -0.04, 95% CI -0.05 to -0.02). Two studies (756 patients) that evaluated HRQOL using SF-36 showed no significant difference between TKA and UKA. Five studies (63,286 patients) that evaluated functional outcomes using Oxford Knee Score (OKS) showed significantly better functional scores for UKA compared to TKA (MD -1.29, 95% CI -1.86 to -0.72). Four studies (24,570 patients) that reported patient satisfaction showed no statistically significant difference between TKA and UKA (MD 0.97, 95% CI 0.90 to 1.05). Further subgroup analysis did not affect the conclusions. CONCLUSIONS Our meta-analysis suggests that UKA is associated with better HRQOL and knee function, as well as similar patient satisfaction, compared to TKA for patients with unicompartmental osteoarthritis.
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Affiliation(s)
- Ke Song
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
- Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), Dezhou, PR China
| | - Liping Qi
- Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), Dezhou, PR China
| | - Zongyou Mu
- Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), Dezhou, PR China
| | - Houyi Sun
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
| | - Shenhao Zhai
- Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), Dezhou, PR China
| | - Dehua Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
| | - Shihao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
| | - Yange Luo
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
| | - Peilai Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, PR China
- Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), Dezhou, PR China
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Green A, Old J, Al-Dadah O. Evaluation of comorbidity scoring systems in patients undergoing knee arthroplasty. J Perioper Pract 2024:17504589241234186. [PMID: 38595039 DOI: 10.1177/17504589241234186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Ageing populations are increasing the demand for knee arthroplasty. Concurrently, the prevalence of medical comorbidities are rising too. The Self-Administered Comorbidity Questionnaire was developed to provide a patient's assessment of their own comorbidities whereas the American Society of Anesthesiologists grades and the Charlson Comorbidity Index utilise clinical evaluation to objectively measure perioperative morbidity and mortality risk. The primary aim of this study was to compare Self-Administered Comorbidity Questionnaire scores with American Society of Anesthesiologists grades and Charlson Comorbidity Index scores. The secondary aim was to compare Self-Administered Comorbidity Questionnaire scores with knee outcome scores. METHODS A single centre observational cohort study of patients with knee osteoarthritis undergoing elective knee arthroplasty. Preoperative evaluation included Self-Administered Comorbidity Questionnaire scores, American Society of Anesthesiologists grades, Charlson Comorbidity Index scores and validated patient-reported outcome measures specific to knee surgery. RESULTS A total of 141 patients were included in this study. Self-Administered Comorbidity Questionnaire scores were directly correlated with American Society of Anesthesiologists grade (rho = 0.37, p < 0.001) and Charlson Comorbidity Index scores (rho = 0.19, p = 0.047). Individual American Society of Anesthesiologists grades had significantly different Self-Administered Comorbidity Questionnaire scores (p = 0.001). Self-Administered Comorbidity Questionnaire scores were specifically associated with hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and the total number of comorbidities, but American Society of Anesthesiologists and Charlson Comorbidity Index scores were associated with more comorbidities. Overall, Self-Administered Comorbidity Questionnaire scores were inversely correlated with patient-reported outcome measure scores. CONCLUSION Self-Administered Comorbidity Questionnaire scores are associated with increasing comorbidity in patients with symptomatic knee osteoarthritis; however, American Society of Anesthesiologists grades and Charlson Comorbidity Index scores had stronger and more abundant associations with comorbidities and patient-reported outcome measure scores. Self-Administered Comorbidity Questionnaires may complement but not replace current objective assessments of comorbidity when evaluating perioperative risk for knee arthroplasty.
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Affiliation(s)
- Alexander Green
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside, UK
| | - Jonathan Old
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside, UK
| | - Oday Al-Dadah
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Lee WS, Park KK, Cho BW, Park JY, Kim I, Kwon HM. Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection. J Orthop Traumatol 2024; 25:6. [PMID: 38347255 PMCID: PMC10861422 DOI: 10.1186/s10195-024-00750-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/18/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The cause of early septic failure after two-stage exchange revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) and the factors affecting it are not well known. The purpose of this study was to determine the surgical outcomes and the risk factors for early septic failure after two-stage revision TKA for chronic PJI. METHODS We identified a total of 246 adult patients who met the Musculoskeletal Infection Society (MSIS) diagnostic criteria for chronic PJI at two academic tertiary hospitals from March 2012 to December 2018. Finally, 151 patients who consecutively received two-stage exchange revision TKA for chronic PJI and who had a minimum 3-year follow-up were enrolled and retrospectively reviewed. Successful surgical treatment was evaluated for two-stage revision TKA and risk factors for early septic failure were identified. RESULTS Early septic failures occurred within 3 years after reimplantation in 48 patients (31.8%). After accounting for potentially confounding variables, we found that male patient [odds ratio (OR): 2.753, 95% confidence interval (CI) 1.099-6.893, p = 0.031], fungus or mycobacterial infection (OR: 5.224, 95% CI 1.481-18.433, p = 0.01), and positive culture at reimplantation (OR: 4.407, 95% CI 1.255-15.480, p = 0.021) were independently associated with early septic failure after two-stage exchange revision TKA. CONCLUSION Male patients, fungus or mycobacterial infection, and positive culture at reimplantation were independently associated with an increased risk of early septic failure after two-stage exchange revision TKA despite normal C-reactive protein values prior to reimplantation. Further prospective and high-quality studies are needed to determine the risk factors of two-stage exchange revision TKA for chronic PJI. LEVEL OF EVIDENCE level IV; retrospective comparison; treatment study.
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Affiliation(s)
- Woo-Suk Lee
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwan Kyu Park
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-Woo Cho
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Young Park
- Department of Orthopaedic Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Gyeonggi-do, Republic of Korea
| | - Inuk Kim
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyuck Min Kwon
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Anastasio AT, Kim BI, Wixted CM, DeOrio JK, Nunley JA, Easley ME, Adams SB. Younger Patients Undergoing Total Ankle Arthroplasty Experience Higher Complication Rates and Worse Functional Outcomes. J Bone Joint Surg Am 2024; 106:10-20. [PMID: 37922342 DOI: 10.2106/jbjs.23.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
BACKGROUND Although many patients with posttraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) have revealed heterogenous results. The purpose of the present study was to determine the effect of age on complication rates and patient-reported outcomes after TAA. METHODS We retrospectively reviewed the records of 1,115 patients who had undergone primary TAA. The patients were divided into 3 age cohorts: <55 years (n = 196), 55 to 70 years (n = 657), and >70 years (n = 262). Demographic characteristics, intraoperative variables, postoperative complications, and patient-reported outcome measures were compared among groups with use of univariable analyses. Competing-risk regression analysis with adjustment for patient and implant characteristics was performed to assess the risk of implant failure by age group. The mean duration of follow-up was 5.6 years. RESULTS Compared with the patients who were 55 to 70 years of age and >70 years of age, those who were <55 years of age had the highest rates of any reoperation (19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001), implant failure (5.6%, 2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.019), and polyethylene exchange (7.7%, 4.3%, and 2.3% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.021). Competing-risk regression revealed a decreased risk of implant failure for patients who were >70 of age compared with those who were <55 years of age (hazard ratio [HR], 0.21 [95% confidence interval (CI), 0.05 to 0.80]; p = 0.023) and for patients who were 55 to 70 years of age compared with those who were <55 years of age (HR, 0.35 [95% CI, 0.16 to 0.77]; p = 0.009). For all subscales of the Foot and Ankle Outcome Score (FAOS) measure except activities of daily living, patients who were <55 years of age reported the lowest (worst) mean preoperative and postoperative scores compared with those who were 55 to 70 years of age and >70 years of age (p ≤ 0.001). Patients who were <55 years of age had the highest mean numerical pain score at the time of the latest follow-up (23.6, 14.4, 12.9 for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001). CONCLUSIONS Studies involving large sample sizes with intermediate to long-term follow-up are critical to reveal age-related impacts on outcomes after TAA. In the present study, which we believe to be the largest single-institution series to date evaluating the effect of age on outcomes after TAA, younger patients had higher rates of complications and implant failure and fared worse on patient-reported outcome measures. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Albert T Anastasio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Billy I Kim
- Duke University School of Medicine, Durham, North Carolina
| | | | - James K DeOrio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Murrell J, Khadabadi NA, Moores T, Hossain F. Identifying Preoperative Predictors for 24-Hour Discharge After Elective Hip and Knee Arthroplasties. Cureus 2023; 15:e50989. [PMID: 38143727 PMCID: PMC10748218 DOI: 10.7759/cureus.50989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.
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Affiliation(s)
- James Murrell
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
| | | | - Thomas Moores
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
| | - Fahad Hossain
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
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Penfold CM, Blom AW, Redaniel MT, Jones T, Eyles E, Keen T, Elliott A, Judge A. The impact of restricted provision of publicly funded elective hip and knee joints replacement during the COVID-19 pandemic in England. PLoS One 2023; 18:e0294304. [PMID: 38019830 PMCID: PMC10686417 DOI: 10.1371/journal.pone.0294304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
AIMS Elective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery. METHODS We included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016-2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic. RESULTS We included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic. CONCLUSIONS The restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements.
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Affiliation(s)
- Chris M. Penfold
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Ashley W. Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Maria Theresa Redaniel
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tim Jones
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Emily Eyles
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tim Keen
- North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - Andrew Elliott
- North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
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Sochart S, Baryeh K, Sochart DH. The use of pre-operative Inferior Vena Cava filters for thromboprophylaxis in ultra-high-risk patients undergoing total hip and knee arthroplasty: a systematic review and narrative analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2749-2764. [PMID: 37000238 PMCID: PMC10063930 DOI: 10.1007/s00590-023-03531-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
PURPOSE Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results. METHODS A systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients. RESULTS Ten studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%). CONCLUSION The use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.
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Affiliation(s)
- Sarita Sochart
- Hyperacute Stroke Unit, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley, GU16 7UJ, UK
| | - Kwaku Baryeh
- Postgraduate Medical Education Department, West Middlesex University Hospital, Twickenham Road, Middlesex, TW7 6AF, UK.
| | - David H Sochart
- The Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, Surrey, KT18 7EG, UK
- The School of Health and Society, The University of Salford, Salford, UK
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8
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Sidhu VS, Kelly TL, Pratt N, Graves SE, Buchbinder R, Adie S, Cashman K, Ackerman IN, Bastiras D, Brighton R, Burns AWR, Chong BH, Clavisi O, Cripps M, Dekkers M, de Steiger R, Dixon M, Ellis A, Griffith EC, Hale D, Hansen A, Harris A, Hau R, Horsley M, James D, Khorshid O, Kuo L, Lewis PL, Lieu D, Lorimer M, MacDessi SJ, McCombe P, McDougall C, Mulford J, Naylor JM, Page RS, Radovanovic J, Solomon M, Sorial R, Summersell P, Tran P, Walter WL, Webb S, Wilson C, Wysocki D, Harris IA. Effect of Aspirin vs Enoxaparin on 90-Day Mortality in Patients Undergoing Hip or Knee Arthroplasty: A Secondary Analysis of the CRISTAL Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2317838. [PMID: 37294566 PMCID: PMC10257098 DOI: 10.1001/jamanetworkopen.2023.17838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/15/2023] [Indexed: 06/10/2023] Open
Abstract
Importance Ischemic heart disease remains the leading cause of mortality following hip and knee arthroplasty. Due to its antiplatelet and cardioprotective properties, aspirin has been proposed as an agent that could reduce mortality when used as venous thromboembolism (VTE) prophylaxis following these procedures. Objective To compare aspirin with enoxaparin in reducing 90-day mortality for patients undergoing hip or knee arthroplasty procedures. Design, Setting, and Participants This study was a planned secondary analysis of the CRISTAL cluster randomized, crossover, registry-nested trial performed across 31 participating hospitals in Australia between April 20, 2019, and December 18, 2020. The aim of the CRISTAL trial was to determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE following hip or knee arthroplasty. The primary study restricted the analysis to patients undergoing total hip or knee arthroplasty for a diagnosis of osteoarthritis only. This study includes all adult patients (aged ≥18 years) undergoing any hip or knee arthroplasty procedure at participating sites during the course of the trial. Data were analyzed from June 1 to September 6, 2021. Interventions Hospitals were randomized to administer all patients oral aspirin (100 mg daily) or subcutaneous enoxaparin (40 mg daily) for 35 days after hip arthroplasty and 14 days after knee arthroplasty procedures. Main Outcomes and Measures The primary outcome was mortality within 90 days. The between-group difference in mortality was estimated using cluster summary methods. Results A total of 23 458 patients from 31 hospitals were included, with 14 156 patients allocated to aspirin (median [IQR] age, 69 [62-77] years; 7984 [56.4%] female) and 9302 patients allocated to enoxaparin (median [IQR] age, 70 [62-77] years; 5277 [56.7%] female). The mortality rate within 90 days of surgery was 1.67% in the aspirin group and 1.53% in the enoxaparin group (estimated difference, 0.04%; 95% CI, -0.05%-0.42%). For the subgroup of 21 148 patients with a nonfracture diagnosis, the mortality rate was 0.49% in the aspirin group and 0.41% in the enoxaparin group (estimated difference, 0.05%; 95% CI, -0.67% to 0.76%). Conclusions and Relevance In this secondary analysis of a cluster randomized trial comparing aspirin with enoxaparin following hip or knee arthroplasty, there was no significant between-group difference in mortality within 90 days when either drug was used for VTE prophylaxis. Trial Registration http://anzctr.org.au Identifier: ACTRN12618001879257.
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Affiliation(s)
- Verinder S Sidhu
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Thu-Lan Kelly
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, New South Wales, Australia
| | - Kara Cashman
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Roger Brighton
- Orthopaedic Department, Westmead Private Hospital, Westmead, Sydney, New South Wales, Australia
- Orthopaedic Department, Lakeview Private Hospital, Baulkham Hills, Sydney, New South Wales, Australia
| | - Alexander W R Burns
- Orthopaedic Department, Calvary John James Hospital, Deakin, Australian Capital Territory, New South Wales, Australia
| | - Beng Hock Chong
- Department of Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Hematology, New South Wales Pathology, Kogarah Campus, Sydney, New South Wales, Australia
| | | | - Maggie Cripps
- Musculoskeletal Australia, Melbourne, Victoria, Australia
| | - Mark Dekkers
- Orthopaedic Department, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Dixon
- Orthopaedic Department, Kareena Private Hospital, Sutherland, New South Wales, Australia
| | - Andrew Ellis
- Orthopaedic Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Elizabeth C Griffith
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - David Hale
- Orthopaedic Department, Hornsby and Kuringai Hospital, Hornsby, New South Wales, Australia
| | - Amber Hansen
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Anthony Harris
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Raphael Hau
- Department of Surgery, Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Mark Horsley
- Orthopaedic Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Dugal James
- Bendigo Healthcare Group, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Omar Khorshid
- Orthopaedic Department, Fremantle Hospital, Fremantle, Perth, Western Australia, Australia
| | - Leonard Kuo
- Orthopaedic Department, Canterbury Hospital, Canterbury, New South Wales, Australia
| | - Peter L Lewis
- Calvary Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Medical Specialties, University of Adelaide, Adelaide, South Australia, Australia
| | - David Lieu
- Orthopaedic Department, Fairfield Hospital, Fairfield, New South Wales, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Samuel J MacDessi
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, New South Wales, Australia
- Orthopaedic Department, St George Private Hospital, Kogarah, New South Wales, Australia
| | - Peter McCombe
- Orthopaedic Department, Frankston Hospital, Frankston, Victoria, Australia
| | - Catherine McDougall
- Orthopaedic Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Jonathan Mulford
- Orthopaedic Department, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Justine Maree Naylor
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Richard S Page
- School of Medicine, St John of God Hospital and Barwon Health, Deakin University, Geelong, Australia
| | - John Radovanovic
- Orthopaedic Department, Mater Hospital, Raymond Terrace, Brisbane, Queensland, Australia
| | - Michael Solomon
- Orthopaedic Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Rami Sorial
- Orthopaedic Department, Nepean Hospital, Penrith, New South Wales, Australia
| | - Peter Summersell
- Orthopaedic Department, Coffs Harbour Base Hospital, Coffs Harbour, New South Wales, Australia
| | - Phong Tran
- Orthopaedic Department, Western Health, Melbourne, Victoria, Australia
| | - William L Walter
- Orthopaedic Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- St John of God Health Care, Perth, Western Australia, Australia
| | - Chris Wilson
- Orthopaedic Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Department of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - David Wysocki
- Orthopaedic Department, Sir Charles Gardiner Hospital, Perth, Western Australia, Australia
| | - Ian A Harris
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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9
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Price A, Thienpont E, Catani F, Abram S, Troelsen A. Consensus statement on unicompartmental knee replacement: A collaboration between BASK and EKS. Knee 2023; 41:391-396. [PMID: 37088518 DOI: 10.1016/j.knee.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND The aim of this study was to deliver consensus recommendations for the clinical practice of unicompartmental knee arthroplasty (UKA). METHODS Members of the British Association for Surgery of the Knee (BASK) and European Knee Society (EKS) were invited to attend a joint meeting in London, UK (December 2019). A formal consensus process was undertaken at the meeting incorporating a multiple round Delphi exercise, with group discussion of areas of agreement and disagreement between rounds. Eighty delegates attended the meeting and five consensus statements were considered and revised, with a threshold level of 80% agreement required as the definition consensus. RESULTS Five consensus statements with accompanying supporting evidence and text were agreed following two rounds of the process: (1) UKA should be offered as a successful alternative to TKA in patients undergoing arthroplasty who meet agreed indications; (2) When consenting a patient for UKA, information including the benefits and risks that are specific to UKA, should be tailored to and discussed with the individual patient; (3) Evidence suggests that surgeons should avoid low-volume use of UKA to optimise outcomes for their patients; (4) Surgeons should use the contemporary evidence-based indications and contraindications for medial UKA; (5) Knee arthroplasty surgeons should have exposure to and training in UKA. CONCLUSIONS The agreed joint BASK-EKS consensus statements on UKA practice are recommended as the contemporary basis of optimal care for these patients and should inform future training and service developments.
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Affiliation(s)
- Andrew Price
- British Association for Surgery of the Knee (BASK); European Knee Society (EKS).
| | | | | | - Simon Abram
- British Association for Surgery of the Knee (BASK)
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10
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Penfold CM, Judge A, Sayers A, Whitehouse MR, Wilkinson JM, Blom AW. Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England : a national population-based cohort study from the National Joint Registry. Bone Joint J 2022; 104-B:1052-1059. [PMID: 36047019 DOI: 10.1302/0301-620x.104b9.bjj-2022-0013.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. METHODS We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. RESULTS We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. CONCLUSION Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care.Cite this article: Bone Joint J 2022;104-B(9):1052-1059.
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Affiliation(s)
- Chris M Penfold
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - J M Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, Sorby Wing, Northern General Hospital, Sheffield, UK.,Centre for Integrated Research into Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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11
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Cook MJ, Lunt M, Board T, O’Neill TW. The impact of frailty on short-term mortality following primary total hip and knee arthroplasty due to osteoarthritis. Age Ageing 2022; 51:6604740. [PMID: 35679192 PMCID: PMC9180921 DOI: 10.1093/ageing/afac118] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We determined the association between frailty and short-term mortality following total hip and knee arthroplasty (THA/TKA) for osteoarthritis and also the impact of THA/TKA on short-term mortality compared with a control population. METHODS Frailty was assessed using a frailty index (categorised: fit, mild, moderate, severe frailty). The association between frailty and short-term mortality following THA/TKA was assessed using Cox regression. Mortality following THA/TKA was also compared with a control population with osteoarthritis but no previous THA/TKA, matched on year of birth, sex and quintile of index of multiple deprivation. RESULTS A total of 103,563 cases who had a THA, 125,367 who had a TKA and matched controls contributed. Among those who had surgery, mortality increased with increasing frailty; adjusted hazard ratio (HR) (95% CI) at 30 days in severely frail versus fit: following THA, 2.85 (1.84, 4.39) and following TKA, 2.14 (1.29, 3.53). The predicted probability of 30-day mortality following THA/TKA varied by age, sex and frailty: following THA, from 0.05% among fit women aged 60-64 years to 6.55% among men with severe frailty aged ≥90 years. All-cause 30-day mortality was increased in fit cases following THA and TKA, respectively, versus fit controls (adjusted HR (95% CI), 1.60 (1.15, 2.21) and 2.98 (1.81, 4.89)), though not among cases with mild, moderate or severe frailty versus controls in the same frailty category. CONCLUSION Short-term mortality increased with increasing frailty following THA/TKA. Comparison of mortality among cases and controls may be affected by a 'healthy surgery' selection effect.
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Affiliation(s)
- Michael J Cook
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Timothy Board
- Department of Trauma and Orthopaedic Surgery, Wrightington Hospital, Wigan, UK
| | - Terence W O’Neill
- Address correspondence to: Terence O’Neill, Centre for Epidemiology Versus Arthritis, The Stopford Building University of Manchester, Oxford Road, Manchester M13 9PT, UK. Tel: (+44) 0161 3060547; Fax: (+44) 161 306 0547. terence.o’
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12
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Matharu GS, Culliford DJ, Blom AW, Judge A. Projections for primary hip and knee replacement surgery up to the year 2060: an analysis based on data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Ann R Coll Surg Engl 2022; 104:443-448. [PMID: 34939832 PMCID: PMC9157920 DOI: 10.1308/rcsann.2021.0206] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We estimated the number of primary total hip and knee replacements (THR and TKR) that will need to be performed up to the year 2060. METHODS We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the volume of primary THRs (n=94,936) and TKRs (n=100,547) performed in 2018. We projected future numbers of THR and TKR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060. RESULTS By 2060, THR and TKR volume would increase from 2018 levels by an estimated 37.7% (n=130,766) and 36.6% (n=137,341), respectively. For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70-79 years (44.6% males, 41.2% females); 80-89 years (112.4% males, 85.6% females); 90 years and older (348.0% males, 198.2% females). CONCLUSION By 2060 demand for hip and knee joint replacement is estimated to increase by almost 40%. Demand will be greatest in older patients (70+ years), which will have significant implications for the health service requiring forward planning given that morbidity and resource use is higher in this population. These issues, coupled with two waves of COVID-19, will impact the ability of health services to deliver timely joint replacement to many patients for a number of years, requiring urgent planning.
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Affiliation(s)
- GS Matharu
- Bristol Medical School, University of Bristol, UK
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13
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Wang B, Zhong JL, Jiang N, Shang J, Wu B, Chen YF, Lu HD. Exploring the Mystery of Osteoarthritis using Bioinformatics Analysis of Cartilage Tissue. Comb Chem High Throughput Screen 2022; 25:53-63. [PMID: 33292128 DOI: 10.2174/1386207323666201207100905] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Osteoarthritis (OA) is a kind of chronic disease relating to joints, which seriously affectsthe daily life activities of the elderly and can also lead to disability. However, the pathogenesis of OA is still unclear, which leads to limited treatment and the therapeutic effect far from people's expectations. This study aims to filter out key genes in the pathogenesis of OA and explore their potential role in the occurrence and development of OA. METHODS The dataset of GSE117999 was obtained and analyzed in order to identify the differentially expressed genes (DEGs), hub genes and key genes. We also identified potential miRNAs which may play a major role in the pathogenesis of OA, and verified their difference in OA by real-time quantitative PCR (RT-qPCR). DGldb was found to serve as an indicator to identify drugs with potential therapeutic effects on key genes and Receiver Operating Characteristic (ROC) analysis was used for identifying underlying biomarkers of OA. RESULTS We identified ten key genes, including MDM2, RB1, EGFR, ESR1, UBE2E3, WWP1, BCL2, OAS2, TYMS and MSH2. Then, we identified hsa-mir-3613-3p, hsa-mir-548e-5p and hsamir- 5692a to be potentially related to key genes. In addition, RT-qPCR confirmed the differential expression of identified genes in mouse cartilage with or without OA. We then identified Etoposide and Everolimus, which were potentially specific to the most key genes. Finally, we speculated that ESR1 might be a potential biomarker of OA. CONCLUSION In this study, potential key genes related to OA and their biological functions were identified, and their potential application value in the diagnosis and treatment of OA has been demonstrated, which will help us to improve the therapeutic effect of OA.
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Affiliation(s)
- Bin Wang
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Jun-Long Zhong
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Ning Jiang
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Jie Shang
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Biao Wu
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Yu-Feng Chen
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
| | - Hua-Ding Lu
- Department of Orthopaedics, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, Guangdong,China
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14
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Yeh HW, Chan CH, Yang SF, Chen YC, Yeh YT, Yeh YT, Huang JY, Yeh CB, Chiu CH. Total knee replacement in osteoarthritis patients on reducing the risk of major adverse cardiac events: a 18-year retrospective cohort study. Osteoarthritis Cartilage 2022; 30:416-425. [PMID: 34800630 DOI: 10.1016/j.joca.2021.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/29/2021] [Accepted: 09/06/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Osteoarthritis (OA) is a common degenerative joint disease, and total knee replacement (TKR) is a successful surgical intervention for knee OA treatment. However, the risks of mortality and major cardiovascular events (MACEs) in patients receiving TKR remain unclear. This study investigated the risks of mortality and MACEs in knee OA patients who received TKR. METHODS For this population-based cohort study, the Longitudinal Health Insurance Database 2000 was used. Two million individuals with knee OA defined by ICD-9-CM codes who received physical therapy between 1999 and 2017 were selected. For propensity score matching (PSM), we considered the year of knee OA diagnosis, demographics, comorbidities, co-medications, and knee OA-related hyaluronic acid or physical therapy at baseline. After PSM, regression analyses were performed to assess the association of mortality or MACEs with TKR and non-TKR individuals. RESULTS We identified patients (n = 189,708) with a new diagnosis of knee OA between 2000 and 2017. In total, 10,314 propensity-score-paired TKR and non-TKR individuals were selected. The PSM cohort algorithm revealed that the risk of mortality or MACEs was lower in the TKR group (adjusted hazard ratio: 0.791; 95% confidence interval: 0.755-0.830) than in the non-TKR group. CONCLUSIONS Patients with knee OA who received TKR had decreased risks of mortality and MACEs than those who did not receive TKR. Moreover, the TKR group received a reduced dosage of nonsteroidal anti-inflammatory drugs at the 1-year follow-up.
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Affiliation(s)
- H-W Yeh
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan; Medical Education Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - C-H Chan
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
| | - S-F Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Y-C Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Y-T Yeh
- School of Dentistry, Chung Shan Medical University, Taichung, Taiwan; Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Y-T Yeh
- School of Dentistry, Chung Shan Medical University, Taichung, Taiwan; Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - J-Y Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - C-B Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
| | - C-H Chiu
- School of Medicine, Chang Gung University, Taoyuan City, Taiwan; Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.
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15
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Yeroushalmi D, Feng J, Nherera L, Trueman P, Schwarzkopf R. Early Economic Analysis of Robotic-Assisted Unicondylar Knee Arthroplasty May Be Cost Effective in Patients with End-Stage Osteoarthritis. J Knee Surg 2022; 35:39-46. [PMID: 32483800 DOI: 10.1055/s-0040-1712088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Unicondylar knee arthroplasty (UKA), as an alternative to total knee arthroplasty (TKA), has been shown to be an effective option for patients with single-compartment end-stage knee osteoarthritis. Implant survival is contingent upon proper alignment, which has been improved with the advent of robotic-assisted surgery (r-UKA), but whether this outweighs the increased cost of the robotic-assist device has not been analyzed in the literature. The purpose of this study was to investigate the mid-term cost-effectiveness of r-UKA compared with UKA with traditional instrumentation (t-UKA) in the United States. A cost-effectiveness analysis using a four-state Markov model was performed using data from the 2018 National Joint Registry of England and Wales and a retrospective multicenter, cohort study on a cohort of 65-year-old patients having undergone r-UKA. The main outcome was cost per revision avoided and sensitivity analyses were conducted to evaluate the impact of using different model assumptions on the results. The Markov model illustrated that the benefit derived from r-UKA versus t-UKA was beneficial from a payer's perspective. The estimated incremental cost-effectiveness ratio (ICER) was $14,737 per revision avoided in a facility seeing 100 patients a year. Case volume was shown to be the primary variable affecting cost-effectiveness, with the value of r-UKA directly increasing with higher case volumes. Cost-effectiveness analyses demonstrated that the use of r-UKA is an effective alternative to t-UKA in patients with single-compartment knee osteoarthritis. While this study could benefit from longer follow-up clinical studies to illustrate the benefits of r-UKAs beyond the current 2 years time horizon, r-UKAs remained cost-effective, even after investigating several different assumptions.
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Affiliation(s)
- David Yeroushalmi
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - James Feng
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Leo Nherera
- Department of Orthopedics, Smith & Nephew Inc, Fort Worth, Texas
| | - Paul Trueman
- Department of Orthopedics, Smith & Nephew Inc, Fort Worth, Texas
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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16
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Williams RD, Reps JM, Rijnbeek PR, Ryan PB, Prieto-Alhambra D. 90-Day all-cause mortality can be predicted following a total knee replacement: an international, network study to develop and validate a prediction model. Knee Surg Sports Traumatol Arthrosc 2022; 30:3068-3075. [PMID: 34870731 PMCID: PMC9418076 DOI: 10.1007/s00167-021-06799-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to develop and validate a prediction model for 90-day mortality following a total knee replacement (TKR). TKR is a safe and cost-effective surgical procedure for treating severe knee osteoarthritis (OA). Although complications following surgery are rare, prediction tools could help identify high-risk patients who could be targeted with preventative interventions. The aim was to develop and validate a simple model to help inform treatment choices. METHODS A mortality prediction model for knee OA patients following TKR was developed and externally validated using a US claims database and a UK general practice database. The target population consisted of patients undergoing a primary TKR for knee OA, aged ≥ 40 years and registered for ≥ 1 year before surgery. LASSO logistic regression models were developed for post-operative (90-day) mortality. A second mortality model was developed with a reduced feature set to increase interpretability and usability. RESULTS A total of 193,615 patients were included, with 40,950 in The Health Improvement Network (THIN) database and 152,665 in Optum. The full model predicting 90-day mortality yielded AUROC of 0.78 when trained in OPTUM and 0.70 when externally validated on THIN. The 12 variable model achieved internal AUROC of 0.77 and external AUROC of 0.71 in THIN. CONCLUSIONS A simple prediction model based on sex, age, and 10 comorbidities that can identify patients at high risk of short-term mortality following TKR was developed that demonstrated good, robust performance. The 12-feature mortality model is easily implemented and the performance suggests it could be used to inform evidence based shared decision-making prior to surgery and targeting prophylaxis for those at high risk. LEVEL OF EVIDENCE III.
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17
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Yapp LZ, Clement ND, Moran M, Clarke JV, Simpson AHRW, Scott CEH. Long-term mortality rates and associated risk factors following primary and revision knee arthroplasty : 107,121 patients from the Scottish Arthroplasty Project. Bone Joint J 2022; 104-B:45-52. [PMID: 34969267 DOI: 10.1302/0301-620x.104b1.bjj-2021-0753.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to determine the long-term mortality rate, and to identify factors associated with this, following primary and revision knee arthroplasty (KA). METHODS Data from the Scottish Arthroplasty Project (1998 to 2019) were retrospectively analyzed. Patient mortality data were linked from the National Records of Scotland. Analyses were performed separately for the primary and revised KA cohorts. The standardized mortality ratio (SMR) with 95% confidence intervals (CIs) was calculated for the population at risk. Multivariable Cox proportional hazards were used to identify predictors and estimate relative mortality risks. RESULTS At a median 7.4 years (interquartile range (IQR) 4.0 to 11.6) follow-up, 27.8% of primary (n = 27,474/98,778) and 31.3% of revision (n = 2,611/8,343) KA patients had died. Both primary and revision cohorts had lower mortality rates than the general population (SMR 0.74 (95% CI 0.73 to 0.74); p < 0.001; SMR 0.83 (95% CI 0.80 to 0.86); p < 0.001, respectively), which persisted for 12 and eighteight years after surgery, respectively. Factors associated with increased risk of mortality after primary KA included male sex (hazard ratio (HR) 1.40 (95% CI 1.36 to 1.45)), increasing socioeconomic deprivation (HR 1.43 (95% CI 1.36 to 1.50)), inflammatory polyarthropathy (HR 1.79 (95% CI 1.68 to 1.90)), greater number of comorbidities (HR 1.59 (95% CI 1.51 to 1.68)), and periprosthetic joint infection (PJI) requiring revision (HR 1.92 (95% CI 1.57 to 2.36)) when adjusting for age. Similarly, male sex (HR 1.36 (95% CI 1.24 to 1.49)), increasing socioeconomic deprivation (HR 1.31 (95% CI 1.12 to 1.52)), inflammatory polyarthropathy (HR 1.24 (95% CI 1.12 to 1.37)), greater number of comorbidities (HR 1.64 (95% CI 1.33 to 2.01)), and revision for PJI (HR 1.35 (95% 1.18 to 1.55)) were independently associated with an increased risk of mortality following revision KA when adjusting for age. CONCLUSION The SMR of patients undergoing primary and revision KA was lower than that of the general population and remained so for several years post-surgery. However, approximately one in four patients undergoing primary and one in three patients undergoing revision KA died within tenten years of surgery. Several patient and surgical factors, including PJI, were associated with the risk of mortality within ten years of primary and revision surgery. Cite this article: Bone Joint J 2022;104-B(1):45-52.
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Affiliation(s)
- Liam Zen Yapp
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Nick D Clement
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Matthew Moran
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK.,Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - A Hamish R W Simpson
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Chloe E H Scott
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
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Shah VI, Pachore JA, Upadhyay S, Shah K, Seth A, Kshatriya A, Patil J, Gujjar P, Kantesariya M. Predictors of 90-Day All-Cause Morbidity, Mortality and Poor Functional Outcome Scores Following Elective Total Knee Arthroplasty in a High-Volume Setting: A Prospective Cohort Study. Indian J Orthop 2021; 56:646-654. [PMID: 35342533 PMCID: PMC8921405 DOI: 10.1007/s43465-021-00559-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 10/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The primary objective was to ascertain the predictors of 90-day all-cause morbidity, mortality and poor functional outcome scores following primary total knee arthroplasty (TKA). MATERIAL AND METHOD The study population comprised 3645 patients who underwent elective primary unilateral TKA at our institution. Demographic variables, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) grade and the Deyo-Charlson comorbidity scores were ascertained. The Functional outcomes, perioperative complications, mortality and readmission rates were monitored prospectively for 90 days and analysed. Patients were assessed twice: at baseline and at 90 days postoperatively. Odds ratio and the corresponding 95% confidence intervals were calculated to quantify the risk. A p < 0.05 for two-tailed tests were considered significant. RESULT The 90-day mortality rate was 0.08% (all males) and 3.95% of the patients experienced one or the other complications. The majority of patients reported excellent-to-poor scores at 90-day follow-up VAS (8.85 ± 1.02 vs. 2.65 ± 1.15; p < 0.0001) and KSS scores (42.96 ± 5.90 vs. 80.52 ± 4.15; p < 0.0001). The early readmission rate was 0.96%. Infection was being the primary reason. Age > 70 years; Deyo-Charlson co-morbidity score ≥ 4, ASA grade-III, Diabetes Mellitus, BMI > 35, Cardiac Issues and Male gender were significant predictors of early morbidity and mortality. Female, Deyo-Charlson comorbidity score ≥ 4, ASA grade-III, BMI > 35, Age > 75 years and poor preoperative scores were significantly associated with poor functional outcome. CONCLUSION The present study explicates the relative importance of predictors on morbidity, mortality and functional outcome. Efforts to minimize morbidity and mortality should concentrate more on elderly male patients, and those with high Deyo-Charlson comorbidity score, BMI and ASA grade.
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Affiliation(s)
- Vikram Indrajit Shah
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Javahir A. Pachore
- Department of Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Sachin Upadhyay
- Department of Orthopaedics, NSCB Medical College, Jabalpur, Madhya Pradesh India
- Department of Trauma and Joints, Shalby Hospitals, Jabalpur, Madhya Pradesh India
| | - Kalpesh Shah
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Ashish Seth
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Amish Kshatriya
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Jayesh Patil
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
| | - Pranay Gujjar
- Department of Knee and Hip Arthroplasty, Shalby Hospitals, Ahmedabad, Gujarat India
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Abram SGF, Sabah SA, Alvand A, Price AJ. Differences in mortality and complication rates following revision knee arthroplasty performed for urgent versus elective indications. Bone Joint J 2021; 103-B:1578-1585. [PMID: 34587801 DOI: 10.1302/0301-620x.103b10.bjj-2020-2590.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIMS To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. METHODS Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. RESULTS A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. CONCLUSION Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J 2021;103-B(10):1578-1585.
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Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Shiraz A Sabah
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Abtin Alvand
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
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Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK. Total versus partial knee replacement in patients with medial compartment knee osteoarthritis: the TOPKAT RCT. Health Technol Assess 2021; 24:1-98. [PMID: 32369436 DOI: 10.3310/hta24200] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Late-stage medial compartment knee osteoarthritis can be treated using total knee replacement or partial (unicompartmental) knee replacement. There is high variation in treatment choice and insufficient evidence to guide selection. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of partial knee replacement compared with total knee replacement in patients with medial compartment knee osteoarthritis. The findings are intended to guide surgical decision-making for patients, surgeons and health-care providers. DESIGN This was a randomised, multicentre, pragmatic comparative effectiveness trial that included an expertise component. The target sample size was 500 patients. A web-based randomisation system was used to allocate treatments. SETTING Twenty-seven NHS hospitals (68 surgeons). PARTICIPANTS Patients with medial compartment knee osteoarthritis. INTERVENTIONS The trial compared the overall management strategy of partial knee replacement treatment with total knee replacement treatment. No specified brand or subtype of implant was investigated. MAIN OUTCOME MEASURES The Oxford Knee Score at 5 years was the primary end point. Secondary outcomes included activity scores, global health measures, transition items, patient satisfaction (Lund Score) and complications (including reoperation, revision and composite 'failure' - defined by minimal Oxford Knee Score improvement and/or reoperation). Cost-effectiveness was also assessed. RESULTS A total of 528 patients were randomised (partial knee replacement, n = 264; total knee replacement, n = 264). The follow-up primary outcome response rate at 5 years was 88% and both operations had good outcomes. There was no significant difference between groups in mean Oxford Knee Score at 5 years (difference 1.04, 95% confidence interval -0.42 to 2.50). An area under the curve analysis of the Oxford Knee Score at 5 years showed benefit in favour of partial knee replacement over total knee replacement, but the difference was within the minimal clinically important difference [mean 36.6 (standard deviation 8.3) (n = 233), mean 35.1 (standard deviation 9.1) (n = 231), respectively]. Secondary outcome measures showed consistent patterns of benefit in the direction of partial knee replacement compared with total knee replacement although most differences were small and non-significant. Patient-reported improvement (transition) and reflection (would you have the operation again?) showed statistically significant superiority for partial knee replacement only, but both of these variables could be influenced by the lack of blinding. The frequency of reoperation (including revision) by treatment received was similar for both groups: 22 out of 245 for partial knee replacement and 28 out of 269 for total knee replacement patients. Revision rates at 5 years were 10 out of 245 for partial knee replacement and 8 out of 269 for total knee replacement. There were 28 'failures' of partial knee replacement and 38 'failures' of total knee replacement (as defined by composite outcome). Beyond 1 year, partial knee replacement was cost-effective compared with total knee replacement, being associated with greater health benefits (measured using quality-adjusted life-years) and lower health-care costs, reflecting lower costs of the index surgery and subsequent health-care use. LIMITATIONS It was not possible to blind patients in this study and there was some non-compliance with the allocated treatment interventions. Surgeons providing partial knee replacement were relatively experienced with the procedure. CONCLUSIONS Both total knee replacement and partial knee replacement are effective, offer similar clinical outcomes and have similar reoperation and complication rates. Some patient-reported measures of treatment approval were significantly higher for partial knee replacement than for total knee replacement. Partial knee replacement was more cost-effective (more effective and cost saving) than total knee replacement at 5 years. FUTURE WORK Further (10-year) follow-up is in progress to assess the longer-term stability of these findings. TRIAL REGISTRATION Current Controlled Trials ISRCTN03013488 and ClinicalTrials.gov NCT01352247. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Loretta J Davies
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Seamus Kent
- Department of Public Health, University of Oxford, Oxford, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jose Leal
- Department of Public Health, University of Oxford, Oxford, UK
| | - Helen Campbell
- Department of Public Health, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Department of Public Health, University of Oxford, Oxford, UK
| | - Nigel Arden
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - David Murray
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
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A comparison of comorbidity measures for predicting mortality after elective hip and knee replacement: A cohort study of data from the National Joint Registry in England and Wales. PLoS One 2021; 16:e0255602. [PMID: 34383814 PMCID: PMC8360555 DOI: 10.1371/journal.pone.0255602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background The risk of mortality following elective total hip (THR) and knee replacements (KR) may be influenced by patients’ pre-existing comorbidities. There are a variety of scores derived from individual comorbidities that can be used in an attempt to quantify this. The aims of this study were to a) identify which comorbidity score best predicts risk of mortality within 90 days or b) determine which comorbidity score best predicts risk of mortality at other relevant timepoints (30, 45, 120 and 365 days). Patients and methods We linked data from the National Joint Registry (NJR) on primary elective hip and knee replacements performed between 2011–2015 with pre-existing conditions recorded in the Hospital Episodes Statistics. We derived comorbidity scores (Charlson Comorbidity Index—CCI, Elixhauser, Hospital Frailty Risk Score—HFRS). We used binary logistic regression models of all-cause mortality within 90-days and within 30, 45, 120 and 365-days of the primary operation using, adjusted for age and gender. We compared the performance of these models in predicting all-cause mortality using the area under the Receiver-operator characteristics curve (AUROC) and the Index of Prediction Accuracy (IPA). Results We included 276,594 elective primary THRs and 338,287 elective primary KRs for any indication. Mortality within 90-days was 0.34% (N = 939) after THR and 0.26% (N = 865) after KR. The AUROC for the CCI and Elixhauser scores in models of mortality ranged from 0.78–0.81 after THR and KR, which slightly outperformed models with ASA grade (AUROC = 0.77–0.78). HFRS performed similarly to ASA grade (AUROC = 0.76–0.78). The inclusion of comorbidities prior to the primary operation offers no improvement beyond models with comorbidities at the time of the primary. The discriminative ability of all prediction models was best for mortality within 30 days and worst for mortality within 365 days. Conclusions Comorbidity scores add little improvement beyond simpler models with age, gender and ASA grade for predicting mortality within one year after elective hip or knee replacement. The additional patient-specific information required to construct comorbidity scores must be balanced against their prediction gain when considering their utility.
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Incidence and risk factors analysis for mortality after total knee arthroplasty based on a large national database in Korea. Sci Rep 2021; 11:15772. [PMID: 34349179 PMCID: PMC8338983 DOI: 10.1038/s41598-021-95346-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
This study aimed to analyze the rates and risk factors of postoperative mortality among 560,954 patients who underwent total knee arthroplasty (TKA) in Korea. The National Health Insurance Service-Health Screening database was used to analyze 560,954 patients who underwent TKA between 2005 and 2018. In-hospital, ninety-day, and one-year postoperative mortality, and their association with patient’s demographic factors and various comorbidities (ie., cerebrovascular disease, congestive heart failure, and myocardial infarction) were assessed. In-hospital, ninety-day and one-year mortality rates after TKA were similar from 2005 to 2018. The risk of in-hospital mortality increased with comorbidities like cerebrovascular disease (hazard ratio [HR] = 1.401; 95% confidence interval [CI] = 1.064–1.844), congestive heart failure (HR = 2.004; 95% CI = 1.394 to 2.881), myocardial infarction (HR = 2.111; 95% CI = 1.115 to 3.998), and renal disease (HR = 2.641; 95% CI = 1.348–5.173). These co-morbidities were also independent predictors of ninety-day and one-year mortality. Male sex and old age were independent predictors for ninety-day and one-year mortality. And malignancy was risk factor for one-year mortality. The common preoperative risk factors for mortality in all periods were male sex, old age, cerebrovascular disease, congestive heart failure, myocardial infarction, and renal disease. Malignancy was identified as risk factor for one-year mortality. Patients with these comorbidities should be provided better perioperative care.
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The effect of surgical approach in total knee replacement on outcomes. An analysis of 875,166 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Knee 2021; 31:144-157. [PMID: 34175672 DOI: 10.1016/j.knee.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/13/2021] [Accepted: 04/10/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee replacement (TKR) is clinically and cost-effective. The surgical approach employed influences the outcome, however there is little generalisable and robust evidence to guide practice. We compared outcomes between the common primary TKR surgical approaches. METHODS 875,166 primary TKRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient reported outcome measures (PROMs) data, with up to 15.75 years follow-up were analysed. There were 10 surgical approach groups: medial parapatellar, midvastus, subvastus, lateral parapatellar, 'other' and their minimally invasive versions. Survival methods were used to compare revision rates and 45-day mortality. Groups were compared using Cox proportional hazards regression and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, TKR fixation, year of primary, body mass index, and for mortality, deprivation and Charlson comorbidity subgroups. PROMs were analysed with regression modelling or non-parametric methods. RESULTS The conventional midvastus approach was associated with lower revision rates (Hazard Rate Ratio (HRR) 0.80 (95% CI 0.71-0.91) P = 0.001) and the lateral parapatellar with higher revision rates (HRR 1.35 (95% CI 1.12-1.63) P = 0.002) compared to the conventional medial parapatellar approach. Mortality rates were similar between approaches. PROMs showed statistically significant, but not clinically important, differences. CONCLUSIONS There is little difference in PROMs between the various surgical approaches in TKR with all resulting in good outcomes. However, the conventional midvastus approach (used in 3% of cases) was associated with a 20% reduced risk of revision surgery compared to the most commonly used knee approach (the conventional medial parapatellar: used in 91.9% of cases). This data supports the use of the midvastus approach and thus surgeons should consider utilising this approach more frequently. Minimally invasive approaches did not appear to convey any clinical advantage in this study over conventional approaches for primary TKR.
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Alvand A, Wilson HA, Sabah SA, Middleton R, Bottomley N, Jackson WFM, Price AJ. New instrumentation system for cementless mobile-bearing unicompartmental knee arthroplasty improves surgical performance particularly for trainees. Knee 2021; 31:46-53. [PMID: 34111801 DOI: 10.1016/j.knee.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mobile-bearing medial-unicompartmental knee arthroplasty (mUKA) has a documented learning curve. New instrumentation has been designed with the aim of reducing the technical challenges of this procedure. The primary aim of this study was to evaluate the technical performance of mUKA using new (Microplasty) versus older (Phase III) instrumentation, performed by expert surgeons and trainees. Secondary aims were to evaluate functional outcome and mid-term survivorship. METHODS A time-based comparative cohort study was performed between 2009 and 2015 at a high-volume centre. 273 patients (273 knees, 49.5% female) of mean age 67.8 (standard deviation 10.1) years underwent mUKA. 153 (56.0%) procedures used Microplasty instruments and 120 procedures (44.0%) used Phase III instruments. RESULTS Non-optimal bearing usage was less frequent with Microplasty than Phase III instruments (24 knees [15.7%] versus 33 knees [27.5%], p = 0.024), with differences due to improved trainee performance. Femoral component sagittal alignment outliers were less frequent with Microplasty, but this was not statistically significant (9 knees [5.9%] versus 13 knees [10.8%], p = 0.18). Post-operative Oxford Knee Scores (OKS) were better with Microplasty (median 42 points [interquartile range 38-44]) compared to Phase III (median 39.5 points [IQR 33-44]), which was statistically significant (p = 0.023), but not clinically meaningful. The overall 5-year Kaplan-Meier (KM) survival estimate was 99.3% (95% CI 97.0-99.8%), with no differences between Microplasty and Phase III instrumentation. CONCLUSIONS New instrumentation improved the reliability of the proximal tibial resection in trainees. Further research is warranted to investigate whether Microplasty instrumentation shortens the learning curve for medial UKA.
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Affiliation(s)
- Abtin Alvand
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom; Nuffield Orthopaedic Centre, Oxford, United Kingdom.
| | - Hannah A Wilson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom
| | - Shiraz A Sabah
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom
| | - Robert Middleton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom
| | | | | | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, United Kingdom; Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Evans JT, Mouchti S, Blom AW, Wilkinson JM, Whitehouse MR, Beswick A, Judge A. Obesity and revision surgery, mortality, and patient-reported outcomes after primary knee replacement surgery in the National Joint Registry: A UK cohort study. PLoS Med 2021; 18:e1003704. [PMID: 34270557 PMCID: PMC8284626 DOI: 10.1371/journal.pmed.1003704] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 06/21/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND One in 10 people in the United Kingdom will need a total knee replacement (TKR) during their lifetime. Access to this life-changing operation has recently been restricted based on body mass index (BMI) due to belief that high BMI may lead to poorer outcomes. We investigated the associations between BMI and revision surgery, mortality, and pain/function using what we believe to be the world's largest joint replacement registry. METHODS AND FINDINGS We analysed 493,710 TKRs in the National Joint Registry (NJR) for England, Wales, Northern Ireland, and the Isle of Man from 2005 to 2016 to investigate 90-day mortality and 10-year cumulative revision. Hospital Episodes Statistics (HES) and Patient Reported Outcome Measures (PROMs) databases were linked to the NJR to investigate change in Oxford Knee Score (OKS) 6 months postoperatively. After adjustment for age, sex, American Society of Anaesthesiologists (ASA) grade, indication for operation, year of primary TKR, and fixation type, patients with high BMI were more likely to undergo revision surgery within 10 years compared to those with "normal" BMI (obese class II hazard ratio (HR) 1.21, 95% CI: 1.10, 1.32 (p < 0.001) and obese class III HR 1.13, 95% CI: 1.02, 1.26 (p = 0.026)). All BMI classes had revision estimates within the recognised 10-year benchmark of 5%. Overweight and obese class I patients had lower mortality than patients with "normal" BMI (HR 0.76, 95% CI: 0.65, 0.90 (p = 0.001) and HR 0.69, 95% CI: 0.58, 0.82 (p < 0.001)). All BMI categories saw absolute increases in OKS after 6 months (range 18-20 points). The relative improvement in OKS was lower in overweight and obese patients than those with "normal" BMI, but the difference was below the minimal detectable change (MDC; 4 points). The main limitations were missing BMI particularly in the early years of data collection and a potential selection bias effect of surgeons selecting the fitter patients with raised BMI for surgery. CONCLUSIONS Given revision estimates in all BMI groups below the recognised threshold, no evidence of increased mortality, and difference in change in OKS below the MDC, this large national registry shows no evidence of poorer outcomes in patients with high BMI. This study does not support rationing of TKR based on increased BMI.
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Affiliation(s)
- Jonathan Thomas Evans
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
- * E-mail:
| | - Sofia Mouchti
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
| | - Ashley William Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Jeremy Mark Wilkinson
- Department of Oncology and Metabolism, The Mellanby Centre for Bone Research, University of Sheffield, Metabolic Bone Unit, Northern General Hospital, Sheffield, United Kingdom
| | - Michael Richard Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Andrew Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, United Kingdom
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Costa D, Cruz EB, Rodrigues AM, Gonçalves-Bradley D, Gomes LA, Donato H, Nunes C. Models of care for patients with knee osteoarthritis in primary healthcare: a scoping review protocol. BMJ Open 2021; 11:e045358. [PMID: 34158296 PMCID: PMC8220471 DOI: 10.1136/bmjopen-2020-045358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Knee osteoarthritis (OA) is a prevalent condition with associated high disability and healthcare costs. Evidence of major gaps in the implementation of evidence-based interventions in people with knee OA led several healthcare systems to implement models of care (MoCs) in order to improve knowledge translation and guaranty their economic sustainability. Nevertheless, there are few studies that analyse the existing body of evidence of MoCs for patients with knee OA in primary healthcare settings. Therefore, we aim to identify MoCs developed for patients with knee OA implemented in primary healthcare and, analyse their core components and outcomes. This scoping review will create knowledge about the components and outcomes of these MoCs which, in the future, will facilitate their transferability to practice. METHODS AND ANALYSIS We will include studies that developed and implemented an MoC for people with knee OA in primary healthcare. We will use the PCC mnemonic, being 'Population'-people with Knee OA, 'Concept'-the MoCs and 'Context'-the primary healthcare setting. We will conduct the search on PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science Core Collection, as well as grey literature databases and relevant institutions and organisations websites, for articles published after 2000. Two independent reviewers will screen titles and abstracts followed by a full-text review to assess papers regarding their eligibility. We will evaluate the methodological quality of the included studies with the Mixed Methods Appraisal tool and apply a data abstraction form to describe and interpret the evidence. ETHICS AND DISSEMINATION As a secondary analysis, this scoping review does not require ethical approval. Findings will be published in peer-review journal, presented in scientific conferences and as a summary through primary healthcare units.
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Affiliation(s)
- Daniela Costa
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), Universidade Nova de Lisboa, Lisboa, Portugal
- EpiDoC Unit - Epidemiology of Chronic Diseases Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Eduardo B Cruz
- Comprehensive Health Research Center (CHRC), Universidade Nova de Lisboa, Lisboa, Portugal
- Physical Therapy Department, School of Health, Polytechnic Institute of Setúbal, Setúbal, Portugal
| | - Ana M Rodrigues
- Comprehensive Health Research Center (CHRC), Universidade Nova de Lisboa, Lisboa, Portugal
- EpiDoC Unit - Epidemiology of Chronic Diseases Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | | | - Luís A Gomes
- Comprehensive Health Research Center (CHRC), Universidade Nova de Lisboa, Lisboa, Portugal
- EpiDoC Unit - Epidemiology of Chronic Diseases Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
- Physical Therapy Department, School of Health, Polytechnic Institute of Setúbal, Setúbal, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Nunes
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), Universidade Nova de Lisboa, Lisboa, Portugal
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Khoshbin A, Hoit G, Nowak LL, Daud A, Steiner M, Juni P, Ravi B, Atrey A. The association of preoperative blood markers with postoperative readmissions following arthroplasty. Bone Jt Open 2021; 2:388-396. [PMID: 34139875 PMCID: PMC8244797 DOI: 10.1302/2633-1462.26.bjo-2021-0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims While preoperative bloodwork is routinely ordered, its value in determining which patients are at risk of postoperative readmission following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is unclear. The objective of this study was to determine which routinely ordered preoperative blood markers have the strongest association with acute hospital readmission for patients undergoing elective TKA and THA. Methods Two population-based retrospective cohorts were assembled for all adult primary elective TKA (n = 137,969) and THA (n = 78,532) patients between 2011 to 2018 across 678 North American hospitals using the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) registry. Six routinely ordered preoperative blood markers - albumin, haematocrit, platelet count, white blood cell count (WBC), estimated glomerular filtration rate (eGFR), and sodium level - were queried. The association between preoperative blood marker values and all-cause readmission within 30 days of surgery was compared using univariable analysis and multivariable logistic regression adjusted for relevant patient and treatment factors. Results The mean TKA age was 66.6 years (SD 9.6) with 62% being females (n = 85,163/137,969), while in the THA cohort the mean age was 64.7 years (SD 11.4) with 54% being female (n = 42,637/78,532). In both cohorts, preoperative hypoalbuminemia (< 35 g/l) was associated with a 1.5- and 1.8-times increased odds of 30-day readmission following TKA and THA, respectively. In TKA patients, decreased eGFR demonstrated the strongest association with acute readmission with a standardized odds ratio of 0.75 per two standard deviations increase (p < 0.0001). Conclusion In this population level cohort analysis of arthroplasty patients, low albumin demonstrated the strongest association with acute readmission in comparison to five other commonly ordered preoperative blood markers. Identification and optimization of preoperative hypoalbuminemia could help healthcare providers recognize and address at-risk patients undergoing TKA and THA. This is the most comprehensive and rigorous examination of the association between preoperative blood markers and readmission for TKA and THA patients to date. Cite this article: Bone Jt Open 2021;2(6):388–396.
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Affiliation(s)
- Amir Khoshbin
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Graeme Hoit
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Anser Daud
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Peter Juni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Bheeshma Ravi
- Division of Orthopaedics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Amit Atrey
- Division of Orthopaedics, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Benignus C, Meier MK, Hirschmann MT, Tibesku CO, Beckmann J. Patientenspezifische Instrumentierung und Teilprothesen am Knie. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00463-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Wang F, Xue H, Ma T, Wen T, Yang T, Xue L, Tu Y. Short-term effectiveness of medial unicompartmental knee arthroplasty in young patients aged less than or equal to 60 years. J Orthop Surg (Hong Kong) 2021; 28:2309499020945118. [PMID: 33034241 DOI: 10.1177/2309499020945118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The treatment for young patients with advanced knee arthritis by Oxford unicompartmental knee arthroplasty (Oxford-UKA) is still controversial. A relative few studies were published about Asian patients. We evaluated midterm results of Oxford-UKA in young patients aged less than or equal to 60 years. METHODS Between December 2009 and December 2018, 95 patients (109 knees) (mean age 57.48 years; range: 33-60 years) were included. The mean follow-up period was 3.0 years (range: 1.0-9.5 years). The functional outcomes and pain score of the knee before and after surgery were examined. RESULTS To the last follow-up, no patient died, six patients (nine knees) were lost and one patient underwent total knee revision in case of unexplained postoperative pain. The patients demonstrated significant improvement in range of knee motion (103.65 vs. 115.96, p < 0.05), Oxford Knee Score (40.0 vs. 14.4, p < 0.05), Hospital for Special Surgery Score (56.0 vs. 85.7, p < 0.05), and Visual Analogue Score (VAS) (5.23 vs. 1.08, p < 0.05) before and after surgery. CONCLUSION Our midterm results showed that the Oxford-UKA was a reliable and effective treatment option for young patients aged less than or equal to 60 years with anterior medial osteoarthritis. The knee pain can be effectively relieved and excellent functional activities of the knee joint can be obtained after surgery.
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Affiliation(s)
- Fangxing Wang
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Huaming Xue
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Tong Ma
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Tao Wen
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Tao Yang
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Long Xue
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
| | - Yihui Tu
- Department of Joint Surgery, 74683Yangpu Hospital Affiliated to Tongji University, Shanghai, China
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Is It Worth Delaying Total Knee Replacement as Late as Possible? A Cost-Effectiveness Analysis Using a Markov Model in the Indian Setting. Value Health Reg Issues 2021; 24:173-180. [PMID: 33831792 DOI: 10.1016/j.vhri.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/02/2020] [Accepted: 12/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Total knee replacement (TKR) is often delayed in younger patients in an attempt to prolong the longevity of the prosthesis and avoid the risk of revision. But delaying a TKR might compromise the quality of life of young patients who are otherwise active and healthy. METHODS We built a Markov decision model to study the simulated clinical course of a 50-year-old patient with severe unilateral knee osteoarthritis who could be either treated with conservative therapies or with a TKR at some point in time. An Indian healthcare payer perspective model was used, and lifetime costs (in Indian rupees), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated. RESULTS In the base case scenario, patients who did not receive a TKR had a total lifetime cost of ₹216 709 and accumulated 13.59 QALYS in their lifetime. Those who received a TKR without delay (at age 50) accumulated 16.71 QALYS in their lifetime with an ICER of ₹9789 per QALY. When TKR was delayed, the total QALYs decreased, and ICER increased with each year of delay. But the cumulative risk of revision decreased from 27.4% when TKR was performed at 50 years to 10.0% when TKR was done at 70 years. CONCLUSION Our analysis found that TKR is a cost-effective procedure when the healthcare payer is willing to pay at least ₹9789 ($132) per QALY. The results also suggested that an early TKR is preferred to a delayed TKR despite the higher incidence of revisions.
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Beckmann J, Hirschmann MT, Matziolis G, Holz J, V Eisenhart-Rothe R, Becher C. [Recommendations for unicondylar knee replacement in the course of time : A current inventory]. DER ORTHOPADE 2021; 50:104-111. [PMID: 33346867 DOI: 10.1007/s00132-020-04054-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND A higher patient satisfaction stands in contrast to higher revision rates of unicondylar knee joint endoprosthetics (UKE) compared to total knee joint endoprosthetics (TKE). Furthermore, old "dogmas" regarding indications and contraindications persist, which is still reflected in the significantly different case numbers. AIM The aim of this article is to provide an overview of the current literature regarding 1. indication and contraindication (BMI, age, sport, arthrosis of other compartments, ligament status) and 2. the "eternal rival" fixed or mobile bearing for UKE. RESULTS The choice of the right patient remains essential, even if all the old "dogmas" of contraindications have been relativized or even outdated. Arthroses of the contralateral (in medial UKE correspondingly lateral) compartment and advanced arthroses of the lateral patella facet remain the only persistent contraindications. In contrast, a high BMI, age, chondrocalcinosis, medial patella facet and a defective (but particularly functionally stable) ACL are not contraindications; however, severe obesity is responsible for a significantly higher complication rate and probably a higher rate of loosening. Rather, the experience and thus the number of UKEs of the individual surgeon is decisive for the outcome, to which the discussion about mobile or fixed inlays must also be completely subordinated. CONCLUSION The indications for UKE can, therefore, be extended with a clear conscience on the basis of literature, and the current 1:10 UKE:TKE ratio in Germany can be shifted significantly.
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Affiliation(s)
- J Beckmann
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland.
| | | | - G Matziolis
- Waldkliniken Eisenberg, Eisenberg, Deutschland
| | - J Holz
- OrthoCentrum Hamburg, Hamburg, Deutschland
| | - R V Eisenhart-Rothe
- Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - C Becher
- IZO - Internationales Zentrum für Orthopädie, ATOS Klinik Heidelberg, Heidelberg, Deutschland
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Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. J Arthroplasty 2021; 36:471-477.e6. [PMID: 33011013 DOI: 10.1016/j.arth.2020.08.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/27/2020] [Accepted: 08/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates. METHODS Using National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs. RESULTS Ten-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases. CONCLUSION UKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.
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Novel clinical and radiological measures of lower limb obesity. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1311-1320. [PMID: 33484345 DOI: 10.1007/s00590-020-02865-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Osteoarthritis of the knee is strongly associated with central obesity, and the prevalence of obesity in patients undergoing knee arthroplasty procedures is expected to increase. Central obesity is associated with multiple adverse outcomes after knee arthroplasty, but the impact of obesity specifically around the operated knee is poorly understood. One reason for this is the absence of a standardized measure, analogous to BMI for central obesity, to facilitate research. The aim of this study was to develop a radiological limb obesity scoring system which reliably corresponds with anthropometric measurements. Detailed anthropometric and radiological measurements were taken from patients undergoing total and unicompartmental knee replacement. Anthropometric measurements were combined into a composite score using principal components analysis. Different radiological scoring methods were evaluated against the anthropometric measure using correlation and regression analyses. Intraclass correlation coefficients were used to evaluate intra- and inter-observer reliability of the radiographic measurements. Measurements were obtained from fifty patients. There was a significant correlation between the composite anthropometric score and unadjusted radiological soft tissue width at the level of the femoral condyles (p < 0.001). There was also a significant correlation with the ratio of tissue to bone widths at the same level (p < 0.001), and fit was improved by including variables coding for soft tissues overlapping the medial or lateral boundaries of the radiograph. We have demonstrated a methodology for producing standardized radiological limb obesity scores which are strongly correlated with anthropometric measurements, and which can be easily applied in diverse clinical and research settings.
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Podmore B, Hutchings A, Skinner JA, MacGregor AJ, van der Meulen J. Impact of comorbidities on the safety and effectiveness of hip and knee arthroplasty surgery. Bone Joint J 2021; 103-B:56-64. [PMID: 33380188 DOI: 10.1302/0301-620x.103b1.bjj-2020-0859.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Access to joint replacement is being restricted for patients with comorbidities in a number of high-income countries. However, there is little evidence on the impact of comorbidities on outcomes. The purpose of this study was to determine the safety and effectiveness of hip and knee arthroplasty in patients with and without comorbidities. METHODS In total, 312,079 hip arthroplasty and 328,753 knee arthroplasty patients were included. A total of 11 common comorbidities were identified in administrative hospital records. Safety risks were measured by assessing length of hospital stay (LOS) and 30-day emergency readmissions and mortality. Effectiveness outcomes were changes in Oxford Hip or Knee Scores (OHS/OKS) (scale from 0 (worst) to 48 (best)) and in health-related quality of life (EQ-5D) (scale from 0 (death) to 1 (full health)) from immediately before, to six months after, surgery. Regression analysis was used to estimate adjusted mean differences (LOS, change in OHS/OKS/EQ-5D) and risk differences (readmissions and mortality). RESULTS Patients with comorbidities had a longer LOS and higher readmission and mortality rates than patients without. In hip arthroplasty patients with heart disease, for example, LOS was 1.20 days (95% confidence interval (CI) 1.15 to 1.25) longer and readmission rate was 1.52% (95% CI 1.34% to 1.71%) and mortality 0.19% (95% CI 0.15% to 0.23%) higher. Similar patterns were observed for knee arthroplasty patients. Patients without comorbidities reported large improvements in function (mean improvement OHS 21.3 (SD 9.91) and OKS 15.9 (SD 10.0)). Patients with comorbidities reported only slightly smaller improvements. In patients with heart disease, mean improvement in OHS was 0.39 (95% CI 0.27 to 0.51) and in OKS 0.56 (95% CI 0.45 to 0.67) less than in patients without comorbidities. There were no significant differences in EQ-5D improvement. CONCLUSION Comorbidities were associated with small increases in adverse safety risks but they have little impact on pain or function in patients undergoing hip or knee arthroplasty. These results do not support restricting access to hip and knee arthroplasty for patients with common comorbidities. Cite this article: Bone Joint J 2021;103-B(1):56-64.
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Affiliation(s)
- Bélène Podmore
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Andrew Hutchings
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - John A Skinner
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, London, UK
| | | | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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Beckmann J, Meier MK, Benignus C, Hecker A, Thienpont E. Contemporary knee arthroplasty: one fits all or time for diversity? Arch Orthop Trauma Surg 2021; 141:2185-2194. [PMID: 34269891 PMCID: PMC8595166 DOI: 10.1007/s00402-021-04042-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) has historically been the preferred solution for any type of knee osteoarthritis, independently of the number of compartments involved. In these days of patient-specific medicine, mono-compartmental disease could also be approached with a more individualized treatment, such as partial knee arthroplasty (PKA). Off-the-shelf (OTS) implants are often the compromise of averages and means of a limited series of anatomical parameters retrieved from patients and the pressure of cost control by limited inventory. Personalized medicine requires respect and interest for the individual shape and alignment of each patient. MATERIALS AND METHODS A Pubmed and Google Scholar search were performed with the following terms: "patient-specific knee" and "arthroplasty" and "custom implant" and "total knee replacement" and "partial knee replacement" and "patellofemoral knee replacement" and "bicompartmental knee replacement". The full text of 90 articles was used to write this narrative review. RESULTS Unicondylar, patellofemoral and bicompartmental knee arthroplasty are successful treatment options, which can be considered over TKA for their bone and ligament sparing character and the superior functional outcome that can be obtained with resurfacing procedures. For TKA, where compromises dominate our choices, especially in patients with individual variations of their personal anatomy outside of the standard, a customized implant could be a preferable solution. CONCLUSION TKA might not be the only solution for every patient with knee osteoarthritis, if personalized medicine wants to be offered. Patient-specific mono-compartmental resurfacing solutions, such as partial knee arthroplasty, can be part of the treatment options proposed by the expert surgeon. Customized implants and personalized alignment options have the potential to further improve clinical outcome by identifying the individual morphotype and respecting the diversity of the surgical population.
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Affiliation(s)
- Johannes Beckmann
- Department of Endoprosthetics, Sportklinik Stuttgart, Stuttgart, Germany
| | - Malin Kristin Meier
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Christian Benignus
- Department of Endoprosthetics, Sportklinik Stuttgart, Stuttgart, Germany
| | - Andreas Hecker
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Wang S, Zhang Y, Li J. [Clinical application of unicompartmental knee arthroplasty and total knee arthroplasty in patient with bilateral knee osteoarthritis]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1568-1573. [PMID: 33319537 DOI: 10.7507/1002-1892.202005065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore whether unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) or bilateral TKAs should be performed in patients with bilateral knee osteoarthritis. Methods Between April 2015 and February 2017, 24 patients with bilateral knee osteoarthritis who met the selection criteria were included in the study and randomly divided into 2 groups ( n=12). The patients in observation group were treated with TKA of the multicompartmental osteoarthritis knee in the first-stage operation and UKA of the unicompartmental osteoarthritis knee in the second-stage operation; and the patients in control group were treated with bilateral TKAs in staging operation. The operation time, the amount of postoperative drainage, and the time of active flexion of the knee joint at 90° were recorded. The difference of hemoglobin (Hb) before and after the second-stage operation was recorded, and the decrease of Hb was observed. The hospital stay after the second-stage operation was observed. The Hospital for Special Surgery (HSS) score, visual analogue scale (VAS) score, and range of motion (ROM) were recorded at 7 days after the first-stage operation, and at 15 days, 45 days, and 6 months after the second-stage operation. At 1 year after the second-stage operation, the mean values of the above indexes of both knees were taken as the individual comprehensive evaluation. The X-ray films were taken regularly to examine the prosthesis and lower extremity force line. Results The incisions in both groups were healed by first intention after two stage operations. The differences in the operation time, the amount of postoperative drainage, and the time of active flexion of the knee joint at 90° between the two groups were not significant in the first-stage operation ( P>0.05) and were significant in the second-stage operation ( P<0.05). The decrease of Hb and hospital stay after the second-stage operation were significantly lower in observation group than in control group ( P<0.05). Both groups were followed up, the follow-up time was 12-18 months (mean, 14 months) in observation group and 12-21 months (mean, 16 months) in control group. During the follow-up period, X-ray films showed that the prosthesis positions of both sides were normal as well as the alignment line, and no infection, loosening or dislocation of prosthesis occurred. There was no significant difference in HSS score, VAS score, and ROM of multicompartmental osteoarthritis knee at 7 days after the first-stage operation between the two groups ( P>0.05), indicating that the two groups were still comparable. The HSS score, VAS score, and ROM of unicompartmental osteoarthritis knee in observation group were superior to control group ( P<0.05) after the second-stage operation. At 1 year, the HSS score, VAS score, and ROM in observation group were also superior to control group ( P<0.05). Conclusion On the premise of strict indications, the patients with bilateral knee osteoarthritis should be treated according to their own pathological changes in order to obtain better short-term effectiveness.
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Affiliation(s)
- Shangzeng Wang
- Department of Joint Surgery, the Second Affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan Province Hospital of Traditional Chinese Medicine, Zhengzhou Henan, 450002, P.R.China
| | - Yingjie Zhang
- Graduate School of Henan University of Traditional Chinese Medicine, Zhengzhou Henan, 450046, P.R.China
| | - Jiwei Li
- Department of Joint Surgery, the Second Affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan Province Hospital of Traditional Chinese Medicine, Zhengzhou Henan, 450002, P.R.China
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Choi HG, Kwon BC, Kim JI, Lee JK. Total knee arthroplasty reduces the risk of mortality in osteoarthritis patients up to 12 years: A Korean national cohort longitudinal follow-up study. J Orthop Surg (Hong Kong) 2020; 28:2309499020902589. [PMID: 32072852 DOI: 10.1177/2309499020902589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Mortality rates and causes of death after total knee arthroplasty (TKA) are of great interest to surgeons. However, there is a shortage of studies regarding those of the Asian population. The aim of this study was to compare the mortality rate and causes of death in patients after TKA to the general population. METHODS National sample cohort data from the Korean Health Insurance Review and Assessment Service were used. In this study, 1:4 matched patients after TKA (TKA group: 5072) and general participants (control group: 20,288) were selected as subjects. Their average follow-up duration was 57.2 months ranging from a year up to 12 years. The matches were processed for age, gender, income, region of residence, and past medical history. Mortality rates and causes of death were compared between groups. Regarding the mortality rates, we also performed subgroup analyses according to age. RESULTS Adjusted hazard ratio (HR) of the TKA group for mortality rate was less than 1 with significance (adjusted HR = 0.61 (95% confidence interval = 0.54-0.70, p < 0.001)). The ratios were less than 1 for both age groups (<70 and ≥70 years), respectively; however, for patients under 70, they were insignificant. Among the 11 major causes of death, the circulatory disease showed the most significantly reduced mortality rate for the TKA group compared to the control group. The neoplasm was the only other cause with a significantly reduced mortality rate for the TKA group. CONCLUSION The mortality rate in the TKA group was significantly lower than in the control group up to 12 years after the surgery in Korea. Among the major causes of death, circulatory disease and neoplasm showed a significant reduction in the mortality rate of the TKA group compared with the control group.
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Affiliation(s)
- Hyo Geun Choi
- Hallym Data Science Laboratory, Hallym University College of Medicine, Gyeonggi-do, Korea.,Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Gyeonggi-do, Korea
| | - Bong Cheol Kwon
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Gyeonggi-do, Korea
| | - Joong Il Kim
- Department of Orthopaedic Surgery, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Joon Kyu Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
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Hutyra CA, Gonzalez JM, Yang JC, Johnson FR, Reed SD, Amendola A, Bolognesi MP, Berend KR, Berend ME, MacDonald SJ, Mather RC. Patient Preferences for Surgical Treatment of Knee Osteoarthritis: A Discrete-Choice Experiment Evaluating Total and Unicompartmental Knee Arthroplasty. J Bone Joint Surg Am 2020; 102:2022-2031. [PMID: 33027086 DOI: 10.2106/jbjs.20.00132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common treatment for end-stage knee osteoarthritis but is associated with increased complication rates compared with unicompartmental knee arthroplasty (UKA). UKA offers better functional outcomes but is associated with a higher risk of revision. The purpose of this study was to apply good-practice, stated-preference methods to quantify patient preferences for benefit-risk tradeoffs associated with arthroplasty treatments for end-stage knee osteoarthritis. METHODS A discrete-choice experiment was developed with the following attributes: chance of complications, functional ability, awareness of the knee implant, and chance of needing another operation within 10 years. Patients included those aged 40 to 80 years with knee osteoarthritis. A pivot design filtered respondents into 1 of 2 surveys on the basis of self-reported functional ability (good compared with fair or poor) as measured by the Oxford Knee Score. Treatment-preference data were collected, and relative attribute-importance weights were estimated. RESULTS Two hundred and fifty-eight completed survey instruments from 92 males and 164 females were analyzed, with 72 respondents in the good-function cohort and 186 in the fair/poor-function cohort. Patients placed the greatest value or relative importance on serious complications and rates of revision in both cohorts. Preference weights did not vary between cohorts for any attribute. In the good-function cohort, 42% of respondents chose TKA and 58% chose UKA. In the fair/poor-function cohort, 54% chose TKA and 46% chose UKA. CONCLUSIONS Patient preferences for various treatment attributes varied among patients in a knee osteoarthritis population. Complication and revision rates were the most important factors to patients, suggesting that physicians should focus on these areas when discussing treatments. The proportion of patients who chose UKA suggests that the current trend of increased UKA utilization is aligned with patient preferences. CLINICAL RELEVANCE Systematic elicitation of patient preferences for knee arthroplasty procedures, which lays out evidence-based risks and benefits of different treatments, indicates a larger subset of the knee osteoarthritis population may prefer UKA than would be suggested by the current rates of utilization of the procedure. Arthroplasty treatment should align with patient preferences and eligibility criteria to better deliver patient-centered care.
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Affiliation(s)
- Carolyn A Hutyra
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Jui-Chen Yang
- Pacific Economic Research, LLC, Bellevue, Washington
| | - F Reed Johnson
- Duke Clinical Research Institute, Durham, North Carolina
| | - Shelby D Reed
- Duke Clinical Research Institute, Durham, North Carolina
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, Ohio.,White Fence Surgical Suites, New Albany, Ohio.,Mount Carmel New Albany Surgical Hospital, New Albany, Ohio
| | | | - Steven J MacDonald
- Division of Orthopaedic Surgery, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Agarwal N, To K, Zhang B, Khan W. Obesity does not adversely impact the outcome of unicompartmental knee arthroplasty for osteoarthritis: a meta-analysis of 80,798 subjects. Int J Obes (Lond) 2020; 45:715-724. [PMID: 33214703 DOI: 10.1038/s41366-020-00718-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 10/13/2020] [Accepted: 11/02/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with end-stage single compartment osteoarthritis benefit from the less invasive unicompartmental knee arthroplasty (UKA). With increasing financial restraints, some healthcare services have set specific BMI cut-offs when determining patient eligibility for knee arthroplasty due to perceived obesity-related complications. The aim of this systematic review is to determine the effect obesity has on outcomes following UKA, and thus elucidate whether obesity should be a contraindication for UKA. METHODS A PRISMA systematic review was conducted using five databases (MEDLINE, EMBASE, Cochrane, PubMed and Web of Science) to identify all clinical studies that examined the effect of obesity on outcomes following UKA. Quantitative meta-analysis was carried out using RevMan 5.3 software. Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist. RESULTS Thirty studies, including a total of 80 798 patients were analysed. The mean follow- up duration was 5.42 years. Subgroup meta-analyses showed no statistically significant difference following UKA between patients cohorts with and without obesity in overall complication rates (95% CI, P = 0.52), infection rates (95% CI, P = 0.81), and revision surgeries (95% CI, P = 0.06). When further analysing complications, no differences were identified in minor (95% CI, P = 0.23) and major complications (95% CI, P = 0.68), or venous thromboembolism rates (95% CI, P = 0.06). When further analysing revision surgeries, no differences were identified for revisions specifically for infection (95% CI, P = 0.71) or aseptic loosening (95% CI, P = 0.75). CONCLUSIONS This meta-analysis shows that obesity does not result in poorer post-operative outcomes following UKA and should not be considered a contraindication for UKA. Future studies, including long-term follow-up RCTs and registry-level analyses, should examine factors associated with obesity and consider stratifying obesity to better delineate any potential differences in outcomes.
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Affiliation(s)
- Nikhil Agarwal
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK. .,MBChB Office, University of Aberdeen College of Life Sciences and Medicine, Foresterhill Rd, Aberdeen, AB25 2ZD, UK.
| | - Kendrick To
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Bridget Zhang
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
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Trela-Larsen L, Kroken G, Bartz-Johannessen C, Sayers A, Aram P, McCloskey E, Kadirkamanathan V, Blom AW, Lie SA, Furnes ON, Wilkinson JM. Personalized estimation of one-year mortality risk after elective hip or knee arthroplasty for osteoarthritis. Bone Joint Res 2020; 9:808-820. [PMID: 33179531 PMCID: PMC7672327 DOI: 10.1302/2046-3758.911.bjr-2020-0343.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS To develop and validate patient-centred algorithms that estimate individual risk of death over the first year after elective joint arthroplasty surgery for osteoarthritis. METHODS A total of 763,213 hip and knee joint arthroplasty episodes recorded in the National Joint Registry for England and Wales (NJR) and 105,407 episodes from the Norwegian Arthroplasty Register were used to model individual mortality risk over the first year after surgery using flexible parametric survival regression. RESULTS The one-year mortality rates in the NJR were 10.8 and 8.9 per 1,000 patient-years after hip and knee arthroplasty, respectively. The Norwegian mortality rates were 9.1 and 6.0 per 1,000 patient-years, respectively. The strongest predictors of death in the final models were age, sex, body mass index, and American Society of Anesthesiologists grade. Exposure variables related to the intervention, with the exception of knee arthroplasty type, did not add discrimination over patient factors alone. Discrimination was good in both cohorts, with c-indices above 0.76 for the hip and above 0.70 for the knee. Time-dependent Brier scores indicated appropriate estimation of the mortality rate (≤ 0.01, all models). CONCLUSION Simple demographic and clinical information may be used to calculate an individualized estimation for one-year mortality risk after hip or knee arthroplasty (https://jointcalc.shef.ac.uk). These models may be used to provide patients with an estimate of the risk of mortality after joint arthroplasty. Cite this article: Bone Joint Res 2020;9(11):808-820.
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Affiliation(s)
- Lea Trela-Larsen
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gard Kroken
- Department of Orthopaedic Surgery, The Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway
| | - Christoffer Bartz-Johannessen
- Department of Orthopaedic Surgery, The Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway
| | - Adrian Sayers
- Department of Orthopaedic Surgery, The Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway
| | - Parham Aram
- Department of Automatic Control and Systems Engineering, University of Sheffield, Sheffield, UK
| | - Eugene McCloskey
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
- MRC-Versus Arthritis Centre for Integrated Research Into Musculoskeletal Ageing (CIMA), University of Sheffield, Sheffield, United Kingdom
| | - Visakan Kadirkamanathan
- Department of Automatic Control and Systems Engineering, University of Sheffield, Sheffield, UK
| | - Ashley W. Blom
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute of Health Research Biomedical Research Centre, Bristol, UK
| | - Stein Atle Lie
- Department of Orthopaedic Surgery, The Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway
| | - Ove Nord Furnes
- Department of Orthopaedic Surgery, The Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - J. Mark Wilkinson
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
- MRC-Versus Arthritis Centre for Integrated Research Into Musculoskeletal Ageing (CIMA), University of Sheffield, Sheffield, United Kingdom
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Age stratified, matched comparison of unicompartmental and total knee replacement. Knee 2020; 27:1332-1342. [PMID: 33010745 DOI: 10.1016/j.knee.2020.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/03/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Unicompartmental knee replacement (UKR) tends to provide better function but has a higher revision rate than total knee replacement (TKR). The aim was to determine if this occurred in all age groups. METHODS Two large, non-registry, prospective cohorts with median 10-year follow-up (2252 TKR, 1000 medial UKR) were identified. All UKR met recommended indications. TKR with an inappropriate disease pattern for medial UKR were excluded. Knees were propensity score-matched within age-strata (<60 years at operation, 60 to <75, 75+) and compared using Oxford Knee Score (OKS), Kaplan-Meier revision rates and a composite failure, defined as any of revision, reoperation or no improvement in OKS. RESULTS One thousand five hundred and eighty-two TKR and UKR were matched. Results are reported TKR vs UKR for ages <60, 60 to <75 and 75+. Median 10-year OKS were 33 vs 45 (p < 0.001), 36 vs 42 (p < 0.001) and 36 vs 38 (p = 0.25). Ten-year revision rates were 11% vs 7%, 5% vs 5%, and 5% vs 10%, (none significant). The composite failures occurred 8%, 5% and 5% more frequently with TKR than UKR (none significant). CONCLUSIONS In this matched study UKR provided better functional outcomes in all age groups, particularly the young, and provided substantially more excellent outcomes. Although in older groups TKR tended to have a lower revision rate, in the young UKR had a lower revision rate. This was surprising and was perhaps because in this study UKR was, as recommended, only used for bone-on-bone arthritis, whereas in young patients it is widely used for early arthritis, which is associated with a high failure rate. This study supports the use of UKR with recommended indications, in all age groups.
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Wiik AV, Nathwani D, Akhtar A, Al-Obaidi B, Strachan R, Cobb JP. The unicompartmental knee is the preferred side in individuals with both a unicompartmental and total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:3193-3199. [PMID: 31781799 PMCID: PMC7511463 DOI: 10.1007/s00167-019-05814-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/19/2019] [Indexed: 11/14/2022]
Abstract
PURPOSE To determine the preferred knee in patients with both one total and one unicompartmental knee arthroplasty. METHOD Patients simply with a unicompartmental (UKA) and total knee arthroplasty (TKA) on contralateral sides were retrospectively screened from three senior knee surgeon's logs over a 15 year period. Patients safe and free from other diseases to affect gait were approached. A total of 16 patients (mean age 70 ± 8) agreed to ground reaction force testing on an instrumented treadmill at a fair pace and incline. A gender-ratio identical group of 16 healthy control subjects (mean age 67 ± 10) and 16 patients with ipsilateral medial knee OA (mean age 66 ± 7) were analysed to compare. RESULTS Radiographically the mode preoperative Kellgren-Lawrence knee grade for each side was 3. Postoperatively, the TKA side had a mean coronal femoral component alignment of 7° and a mean tibial coronal alignment of 89° with a mean posterior slope of 5° in the sagittal plane. The UKA side had a mean coronal femoral component alignment of 7° and a mean tibial coronal alignment of 86° with a mean posterior slope of 4° in the sagittal plane. In 7 patients, the TKA was the first procedure, while 6 for the UKA and 3 done simultaneously. Gait analysis demonstrated in both walking conditions the UKA limb was the preferred side through all phases of loading (p < 0.05) and nearer to normal than the TKA limb when compared to healthy controls and patients with knee OA. The greatest difference was observed between the transition of weight acceptance and midstance (p = 0.008), when 22% more load was taken by the UKA side. CONCLUSION By using a dynamic metric of an everyday activity, a distinct gait difference between differing arthroplasty types were established. A more natural loading pattern can be achieved with unicompartmentals as compared to total knees. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
| | - Dinesh Nathwani
- Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - Ahsan Akhtar
- Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - Bilal Al-Obaidi
- Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - Robin Strachan
- Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, UK
| | - Justin Peter Cobb
- Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, UK
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Matharu GS, Garriga C, Whitehouse MR, Rangan A, Judge A. Is Aspirin as Effective as the Newer Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Total Hip and Knee Arthroplasty? An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. J Arthroplasty 2020; 35:2631-2639.e6. [PMID: 32532481 DOI: 10.1016/j.arth.2020.04.088] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/22/2020] [Accepted: 04/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Few studies have compared aspirin with direct oral anticoagulants (DOACs) (DOACs = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis after THA and TKA using the world's largest joint arthroplasty registry. METHODS We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THA and TKA patients. Patients receiving aspirin were matched separately to patients receiving direct thrombin inhibitors and factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events. RESULTS After THA, there was a significantly lower risk of VTE associated with the use of direct thrombin inhibitors (0.44%; odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.55-0.87; P = .002) and factor Xa inhibitors (0.37%; OR, 0.63; 95% CI, 0.47-0.85; P = .003) compared with aspirin (0.63%). After THA, direct thrombin inhibitors (coefficient, -0.37 days; 95% CI, -0.43 to -0.31; P < .001) and factor Xa inhibitors (coefficient, -0.80 days; 95% CI, -0.87 to -0.74; P < .001) were associated with a reduced length of stay compared with aspirin. Similar findings for both outcomes were observed after TKA. Compared with aspirin, DOACs were not associated with an increase in the risk of short-term revision surgery, reoperation, major hemorrhage, wound disruption, surgical site infection, and mortality. CONCLUSION After THA and TKA, DOACs were associated with a reduced risk of VTE compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs were not associated with an increase in the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
| | - Cesar Garriga
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Michael R Whitehouse
- Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man; Department of Health Sciences, University of York, Heslington, York, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Translational Health Sciences, Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom
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JointCalc: A web-based personalised patient decision support tool for joint replacement. Int J Med Inform 2020; 142:104217. [PMID: 32853974 PMCID: PMC7607377 DOI: 10.1016/j.ijmedinf.2020.104217] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022]
Abstract
JointCalc is the first complete web decision support tool for joint replacement. User-centred design helps avoid common health information system design. Modern software production methods synergise with and enable user-centred design. JointCalc implementation supports claims of high efficiency of eHealth.
Background and purpose Health information systems (HIS) are expected to be effective and efficient in improving healthcare services, but empirical observation of HIS reveals that most perform poorly in terms of these metrics. Theoretical factors of HIS performance are widely studied, and solutions to mitigate poor performance have been proposed. In this paper we implement effective methods to eliminate some common drawbacks of HIS design and demonstrate the synergy between the methods. JointCalc, the first comprehensive patient-facing web-based decision support tool for joint replacement, is used as a case study for this purpose. Methods and results User-centred design and thorough end-user involvement are employed throughout the design and development of JointCalc. This is supported by modern software production paradigms, including continuous integration/continuous development, agile and service-oriented architecture. The adopted methods result in a user-approved application delivered well within the scope of project. Conclusion This work supports the claims of high potential efficiency of HIS. The methods identified are shown to be applicable in the production of an effective HIS whilst aiding development efficiency.
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Mishra D, Nanda SN, Samant S, Tripathy SK, Gachhayat A, J GV. Short-Term Functional Outcome and Satisfaction Rate of Unicompartmental Knee Arthroplasty in Indian Population: A Retrospective Study. Cureus 2020; 12:e9033. [PMID: 32782855 PMCID: PMC7410404 DOI: 10.7759/cureus.9033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction: Unicompartmental knee arthroplasty (UKA) is a procedure used to treat isolated medial or lateral compartmental osteoarthritis of the knee joint. This procedure involves retention of cruciate ligaments which leads to better functional outcome due to preservation of normal kinematics of the knee joint. In the Indian population, due to requirement of squatting and cross leg sitting habits, knee with more range of movement and with good kinematics is a required feature. The study aims to observe the functional outcome, mortality, revision rate, length of hospital stay and satisfaction rate in two-year postoperative patients in a tertiary health care centre. Methods: A total of 17 knees of 15 patients were recruited for the study after applying strict inclusion and exclusion criteria. These patients were operated during the period from March 2015 to March 2018. Ten female patients (67%) and five males (33%) were included. The average age was 61 years. All operations were performed by a single surgeon, with a similar implant from a single company. Similar protocol was used both for surgical technique (minimal invasive) and postoperative rehabilitation for all the patients. Results: The functional outcome in the form of Oxford Knee Score (OKS) and Euro-Quol (EQ-5D) scores improved significantly in all the patients at one year postoperatively, and the improvement remained significant for two years. Satisfaction rate was 91.7% (SD-12.8) at two years. Except for one patient (5.8%), all patients were able to cross leg and squat easily. At the end of two years, the overall survival rate of the implant was found to be 94.1%. Conclusion: The unicondylar arthroplasty provides excellent satisfaction to the appropriately selected patients with good survivorship of implant. It can be a surgery of choice for Indian population as it restores normal kinematics of knee joint and allows the patient to cross leg and squat with a more range of movement.
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Affiliation(s)
- Debashish Mishra
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Saurav N Nanda
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Saswat Samant
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND.,Orthopaedics, Apollo Hospital, Bhubaneswar, IND
| | | | - Ashok Gachhayat
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Govind V J
- Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Liow MHL, Goh GS, Pang HN, Tay DKJ, Chia SL, Lo NN, Yeo SJ. Should patients aged 75 years or older undergo medial unicompartmental knee arthroplasty? A propensity score-matched study. Arch Orthop Trauma Surg 2020; 140:949-956. [PMID: 32306091 DOI: 10.1007/s00402-020-03440-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION With increasing life expectancies worldwide, more elderly patients with isolated medial compartment osteoarthritis may become suitable UKA candidates. However, there is a paucity of literature comparing outcomes between older patients (≥ 75 years) and younger patients undergoing UKA. The aim of this study was to determine if there were differences in functional and HRQoL measures between older patients (≥ 75 years) and younger controls (< 75 years) undergoing primary UKA. MATERIALS AND METHODS Prospectively collected registry data of 1041 patients who underwent primary, cemented, fixed-bearing medial UKA at a single institution from 2002-2013 were reviewed. Propensity scores generated using logistic regression was used to match older patients (≥ 75 years, n = 94) to controls (< 75 years, n = 188) in a 1:2 ratio. Knee Society Scores, Oxford Knee Score, Short Form-36, satisfaction/expectation scores, proportion of patients attaining OKS/SF-36 PCS MCID and survivorship were analysed. RESULTS Patients ≥ 75 years had significantly lower KSFS (67.1 ± 17.9 vs 79.4 ± 18.2, p < 0.001) and SF-36 PCS (47.3 ± 10.1 vs 50.4 ± 9.1, p = 0.01) as compared to the control group. In addition, a significantly lower proportion of patients ≥ 75 years attained MCID for SF-36 PCS when compared to the controls (50.0% vs 63.8%, p = 0.04). Survival rates at mean 8.3 ± 3.0 years were 98.9% (95% CI, 96.7-100) in the older group versus 92.8% (95% CI, 86.8-98.8) in the younger group (p = 0.31). CONCLUSIONS Our findings highlight the need to counsel older patients regarding potentially reduced improvements in functional outcomes, despite advantages of lower revision. However, UKA in older patients continues to be a viable option for isolated medial compartment osteoarthritis LEVEL OF EVIDENCE: Level III Propensity score matched study.
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Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Graham S Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore.
| | - Hee-Nee Pang
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Darren Keng-Jin Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Ngai-Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
| | - Seng-Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865, Singapore
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Matharu GS, Garriga C, Rangan A, Judge A. Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. J Arthroplasty 2020; 35:1521-1528.e5. [PMID: 32216984 DOI: 10.1016/j.arth.2020.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/13/2020] [Accepted: 02/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Regional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world's largest joint replacement registry. METHODS We studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes. RESULTS Length of stay was reduced with regional anesthesia compared with general anesthesia (THR = -0.49 days, 95% confidence interval [CI] = -0.51 to -0.47 days, P < .001; TKR = -0.47 days, CI = -0.49 to -0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality. CONCLUSION Regional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Musculoskeletal Research Unit, Department of Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Cesar Garriga
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Musculoskeletal Research Unit, Department of Translational Health Sciences, University of Bristol, Bristol, United Kingdom
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Dacombe P, Harries L, McCann P, Crowther M, Packham I, Sarangi P, Whitehouse MR. Predictors of mortality following shoulder arthroplasty. J Orthop 2020; 22:179-183. [PMID: 32419761 DOI: 10.1016/j.jor.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction This study aims to determine 30-day, 90-day and 1 year mortality following shoulder arthroplasty and identify predictors of mortality. Materials and methods All shoulder arthroplasty cases performed at the host institution, between 2012 and 2018 were included. A review of patient records was completed to identify demographic data, Charlson comorbidity index, date of death and factors associated with mortality.Mortality analysis was undertaken using 1-Kaplan Meier estimates with 95% confidence intervals. Comparative analysis was performed for mortality following shoulder arthroplasty for elective vs. trauma and for primary vs. revision surgery. A multiple regression analysis was conducted to determine which factors were associated with increased mortality risk. Results 640 shoulder arthroplasty cases were performed in 566 patients. There were 44 deaths, 1 occurred within 90 days and 13 within 1 year. Trauma procedures had a hazard ratio of 5.3 (95% CI 1.9 to 15.0) for mortality compared to elective procedures (5 year survival trauma 78.6% (95% CI 60.7 to 89.0); elective 91.8% (95% CI 88.1 to 94.4). 1-year mortality was predicted by presence of malignancy, liver failure, cardiac failure, peptic ulcer, trauma surgery, revision surgery, intra-operative complication, transfusion and increased length of stay. Discussion 30-day, 90-day and 1-year mortality following shoulder arthroplasty were 0%, 0.16% and 2%; trauma procedures had a hazard ratio of 5.3 for 1-year mortality when compared to elective surgery. Malignancy, cardiac failure, liver failure, peptic ulcer and trauma surgery are associated with an increased risk of 1-year mortality.
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Affiliation(s)
- P Dacombe
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK
| | - L Harries
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK
| | - P McCann
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK.,Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, UK
| | - M Crowther
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK
| | - I Packham
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK
| | - P Sarangi
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK
| | - M R Whitehouse
- Avon Orthopaedic Centre, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol, BS10 5NB, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristo, UK
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Early Economic Evaluation Demonstrates That Noncomputerized Tomography Robotic-Assisted Surgery Is Cost-Effective in Patients Undergoing Unicompartmental Knee Arthroplasty at High-Volume Orthopaedic Centres. Adv Orthop 2020; 2020:3460675. [PMID: 32351739 PMCID: PMC7178538 DOI: 10.1155/2020/3460675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 11/18/2022] Open
Abstract
Background For over fifty years, unicompartmental knee arthroplasty (UKA) has been used to treat single-compartment osteoarthritis of the knee and is considered a safe alternative to total knee arthroplasty (TKA). The development and use of robotic-assisted surgery (r-UKA) have made the execution of the procedure more precise, and various studies have reported improved radiographic outcomes and implant survival rates; however, its cost-effectiveness is unknown. This study aimed at assessing the cost-effectiveness of noncomputerized tomography (non-CT) r-UKA compared to the traditional unicompartmental knee arthroplasty (t-UKA) method in patients with unicompartmental knee osteoarthritis from the UK payer's perspective. Methods We developed a 5-year four-state Markov model to evaluate the expected costs and outcomes of the two strategies in patients aged 65 years. Failure rates for t-UKA were taken from the British National Joint Registry while data for non-CT r-UKA were obtained from a 2-year observational study. Cost was obtained from the NHS reference cost valued at 2018/19 GBP£, and a discount rate of 3.5% was applied to both costs and benefits. Results For a high-volume orthopaedic centre that performs 100 UKA operations per year, non-CT r-UKA was more costly than t-UKA but offered better clinical outcomes, and the estimated cost per QALY was £2,831. The results were more favourable in younger patients aged less than 55 and sensitive to case volumes and follow-up period. Conclusion Non-CT r-UKA is cost-effective compared with t-UKA over a 5-year period. Results are dependent on case volumes and follow-up period and favour younger age groups.
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50
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Crawford DA, Berend KR, Thienpont E. Unicompartmental Knee Arthroplasty: US and Global Perspectives. Orthop Clin North Am 2020; 51:147-159. [PMID: 32138853 DOI: 10.1016/j.ocl.2019.11.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Unicompartmental knee arthroplasty (UKA) is a treatment option for anteromedial osteoarthritis. Compared with total knee arthroplasty (TKA), UKA offers improved knee range of motion, functional recovery and decreased medical complications. Revision rates continue to be higher with UKA compared with TKA. With current UKA implants, there is no significant difference in mobile bearing or fixed bearing, or between cemented and cementless implants. Enabling technology, such as robotic-assisted surgery, has demonstrated improvements in component positioning, but no long-term difference in survival compared with traditional manual instruments.
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Affiliation(s)
- David A Crawford
- JIS Orthopedics, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA.
| | - Keith R Berend
- JIS Orthopedics, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA
| | - Emmanuel Thienpont
- Cliniques universitaires Saint Luc, Avenue Hippocrate 10, Brussels 1200, Belgium
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