Fast-tracking for total knee replacement reduces use of institutional care without compromising quality

Readmission rate and early complications in patients undergoing total knee arthroplasty: A retrospective study

BACKGROUND

Total knee arthroplasty (TKA) can improve pain, quality of life, and functional outcomes. Although uncommon, postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery. Identification of the risk factors for complications and readmissions after TKA, taking into account common causes, temporal trends, and risk variables that can be changed or left unmodified, will benefit this process.

AIM

To assess readmission rates, early complications and their causes after TKA at 30 days and 90 days post-surgery.

METHODS

This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1, 2017, and February 28, 2022. Of the 633 patients, 28 were not contactable, leaving 609 who met the inclusion criteria. Both inpatient and outpatient hospital records were retrieved, and observations were noted in the data collection forms.

RESULTS

Following TKA, the 30-day and 90-day readmission rates were determined to be 1.1% (n = 7) and 1.8% (n = 11), respectively. The unplanned visit rate at 30 days following TKA was 2.6% (n = 16) and at 90 days was 4.6% (n = 28). At 90 days, the unplanned readmission rate was 1.4% (n = 9). Reasons for readmissions included medical (27.2%, n = 3) and surgical (72.7%, n = 8). Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group (P = 0.922), body mass index (BMI) (P = 0.633), unilateral vs bilateral TKA (P = 0.696), or patient comorbidity status (30-day P = 0.171 and 90-day P = 0.813). Reoperation rates after TKA were 0.66% (n = 4) at 30 days and 1.15% (n = 8) at 90 days. The average length of stay was 6.53 days.

CONCLUSION

In this study, there was a low readmission rate following TKA. There was no significant correlation between readmission rate and patient factors such as age, BMI, and co-morbidity status.

Risk stratification-based thromboprophylaxis does not affect mortality after fast-track hip and knee arthroplasty

BACKGROUND AND PURPOSE

Use of thromboprophylaxis effectively prevents pulmonary embolism (PE) and deaths after total hip and knee arthroplasty (THA and TKA). The optimum length of thromboprophylaxis is not known and has traditionally been based on the type of operation. Nowadays, a more individualized approach is preferred. This study analyzed if risk stratification-based planning of thromboprophylaxis has an association with the all-cause mortality after fast-track THA and TKA.

PATIENTS AND METHODS

We compared fast-track THAs and TKAs operated between 2015-2016 and 2020-2021. Between 2015 and 2016, all patients received a routine length of thromboprophylaxis. From 2020 onwards, thromboprophylaxis was planned by risk stratification, and patients at low risk for venous thromboembolism received thromboprophylaxis only during hospitalization. All causes of death within 90 days of surgery were identified and the incidence of mortality was calculated. Mortality rates between the two periods were then compared.

RESULTS

Between 2015 and 2016, 3192 arthroplasties were performed. A total of eight deaths occurred within 90 days of surgery, yielding an incidence of all-cause mortality of 0.3% (95% CI 0.1-0.5). Between 2020 and 2021, a total of 3713 arthroplasties were performed to patients who received risk stratification-based thromboprophylaxis. Thirteen of these patients died within 90 days of surgery, yielding an all-cause mortality incidence of 0.4% (95% CI 0.2-0.6). Cardiovascular diseases were the main cause of death during both study periods. None of the deaths were caused by PEs.

INTERPRETATION

Risk stratification-based thromboprophylaxis was not associated with increased all-cause mortality within 90 days of fast-track THA and TKA.

Return to Work Following Hip or Knee Arthroplasty: A One-Year Prospective Cohort Study in Participants with Direct Referral from Hospital to Occupational Health Care Services

PURPOSE

In a new Finnish Coordinated Return to Work (CRTW) model, patients are referred to occupational health care after hip or knee arthroplasty. This study evaluated the CRTW model's effect on return to work (RTW), activities used in occupational health care and in the workplace, and the patient- and work-related factors affecting early RTW.

METHODS

209 participants with occupational health care service underwent primary hip (THA) or total/unicondylar knee (KJA) arthroplasty and completed self-reported questionnaires after arthroplasty and at time of RTW. Factors affecting RTW, and the roles of occupational health care and the workplace in RTW were evaluated. Time to RTW was determined as days between the arthroplasty and RTW.

RESULTS

Mean time to RTW was 69 days after THA and 87 days after KJA. For easing RTW, work arrangements were made for 56% of the participants. The most utilized adjustments of work were enabling remote work and arranging limitations in work tasks. Participants with earlier RTW had lower physical workload, higher professional status and motivation to work, less pre-arthroplasty sick leave, and more positive personal expectations about the time to RTW compared to participants with later RTW (p < 0.001 for all). The linear regression and dominance analyses showed participants' own expectations and pre-arthroplasty sick leave as the strongest factors affecting time to RTW.

CONCLUSIONS

The CRTW model seems to shorten time to RTW after THA and KJA. Occupational health care and workplace play important roles in supporting RTW. Patients' own expectations should be noted when giving pre-arthroplasty information.

Enhanced recovery after surgery in patients after hip and knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Enhanced recovery after surgery (ERAS) was characterized as patient-centered, evidence-based, multidisciplinary team-developed routes for a surgical speciality and institution to improve postoperative recovery and attenuate the surgical stress response. However, evidence of their effectiveness in osteoarthroplasty remains sparse. This study aimed to develop an ERAS standard and evaluate the significance of ERAS interventions for postoperative outcomes after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We searched Medline, Embase, Cochrane databases, and Clinicaltrials.gov for randomized controlled trials, cohort studies, and case-control studies until 24 February 2023. All relevant data were collected from studies meeting the inclusion criteria. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was the length of stay (LOS), postoperative complications, and readmission rate. The secondary outcomes included transfusion rate, mortality rate, visual analog score (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form 36 (SF-36) bodily pain (SF-36 BP), SF-36 physical function (SF-36 PF), oxford knee score, and range of motion (ROM).

RESULTS

A total of 47 studies involving 76 971 patients (ERAS group: 29 702, control group: 47 269) met the inclusion criteria and were included in the meta-analysis. The result showed that ERAS could significantly shorten the LOS (WMD = -2.65, P < .001), reduce transfusion rate (OR = 0.40, P < .001), and lower 30-day postoperative mortality (OR = 0.46, P = .01) without increasing postoperative complications or readmission rate. Apart from that, ERAS may decrease patients' VAS (WMD = -0.88, P = .01) while improving their ROM (WMD = 6.65, P = .004), SF-36 BP (WMD = 4.49, P < .001), and SF-36 PF (WMD = 3.64, P < .001) scores. However, there was no significant difference in WOMAC, oxford knee score between the ERAS and control groups.Furthermore, we determined that the following seven components of the ERAS program are highly advised: avoid bowel preparation, PONV prophylaxis, standardized anesthesia, use of local anesthetics for infiltration analgesia and nerve blocks, tranexamic acid, prevent hypothermia, and early mobilization.

CONCLUSION

Our meta-analysis suggested that the ERAS could significantly shorten the LOS, reduce transfusion rate, and lower 30-day postoperative mortality without increasing postoperative complications or readmission rate after THA and TKA. Meanwhile, ERAS could decrease the VAS of patients while improving their ROM, SF-36 BP, and SF-36 PF scores. Finally, we expect future studies to utilize the seven ERAS elements proposed in our meta-analysis to prevent increased readmission rate for patients with THA or TKA.

Home-based tele-rehabilitation versus hospital-based outpatient rehabilitation for pain and function after initial total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aims to compare the effectiveness of home-based tele-rehabilitation programs with hospital-based rehabilitation programs in improving pain and function at various time points (≤6 weeks, ≤14 weeks, and ≤ 52 weeks) following the initial total knee arthroplasty.

METHODS

This study used PRISMA and AMSTAR reporting guidelines. We systematically searched 5 databases (PubMed, Embase, Web of Science, Cochrane Library, and Medline) to identify randomized controlled trials published from January 1, 2019, to January 1, 2023. The primary outcomes were pain, knee injury and osteoarthritis outcome score, and mobility (knee range of motion).

RESULTS

We included 9 studies involving 1944 patients. Low-quality evidence showed hospital-based rehabilitation was better than home-based tele-rehabilitation in knee injury and osteoarthritis outcome score (mean difference [MD], -2.62; 95% confidence interval [CI], -4.65 to -0.58; P = .01) at ≤ 14 weeks after total knee arthroplasty. Based on low-quality evidence, home-based tele-rehabilitation was better than hospital-based rehabilitation in knee range of motion (MD, 2.00; 95% CI, 0.60 to 3.40; P = .005). There was no significant difference between hospital-based rehabilitation and home-based tele-rehabilitation in knee pain at ≤ 6 weeks (MD, 0.18; 95% CI, -0.07 to 0.42; P = .16), 14 weeks (MD, 0.12; 95% CI, -0.26 to 0.49; P = .54), and ≤ 52 weeks (MD, 0.16; 95% CI, -0.11 to 0.43; P = .24).

CONCLUSION

Home-based tele-rehabilitation and hospital-based rehabilitation programs showed comparable long-term outcomes in pain, mobility, physical function, and patient-reported health status after primary total knee arthroplasty. Considering the economic costs, home-based tele-rehabilitation programs are recommended as a viable alternative to hospital-based rehabilitation programs.

Does interaction occur between risk factors for revision total knee arthroplasty?

INTRODUCTION

Several risk factors for revision TKA have previously been identified, but interactions between risk factors may occur and affect risk of revision. To our knowledge, such interactions have not been previously studied. As patients often exhibit multiple risk factors for revision, knowledge of these interactions can help improve risk stratification and patient education prior to TKA.

MATERIALS AND METHODS

The State Inpatient Databases (SID), part of the Healthcare Cost and Utilization Project (HCUP), were queried to identify patients who underwent TKA between January 1, 2006 and December 31, 2015. Risk factors for revision TKA were identified, and interactions between indication for TKA and other risk factors were analyzed.

RESULTS

Of 958,944 patients who underwent TKA, 33,550 (3.5%) underwent revision. Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA were significantly associated with revision (p < 0.05). Age was the strongest predictor (p  < 0.0001), with younger patients exhibiting higher revision risk. Risks associated with age were modified by an interaction with indication for TKA (p < 0.0001). There was no significant interaction between sex and indication for TKA (p = 0.535) or race and indication for TKA (p = 0.187).

CONCLUSIONS

Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA are significantly associated with revision TKA. Interaction occurs between age and indication.

Length of stay and inpatient charges of total knee arthroplasty in China: analysis of a national database

BACKGROUND

There are limited data on the resource utilization of total knee arthroplasty (TKA) in China. This study aimed to examine the length of stay (LOS) and inpatient charges of TKA in China, and to investigate their determinants.

METHODS

We included patients undergoing primary TKA in the Hospital Quality Monitoring System in China between 2013 and 2019. LOS and inpatient charges were obtained, and their associated factors were further assessed using multivariable linear regression.

RESULTS

A total of 184,363 TKAs were included. The LOS decreased from 10.8 days in 2013 to 9.3 days in 2019. The admission-to-surgery interval decreased from 4.6 to 4.2 days. The mean inpatient charges were 61,208.3 Chinese Yuan. Inpatient charges reached a peak in 2016, after which a gradual decrease was observed. Implant and material charges accounted for a dominating percentage, but they exhibited a downward trend, whereas labor-related charges gradually increased. Single marital status, non-osteoarthritis indication, and comorbidity were associated with longer LOS and higher inpatient charges. Female sex and younger age were associated with higher inpatient charges. There were apparent varieties of LOS and inpatient charges among provincial or non-provincial hospitals, hospitals with various TKA volume, or in different geographic regions.

CONCLUSIONS

The LOS following TKA in China appeared to be long, but it was shortened during the time period of 2013 to 2019. The inpatient charges dominated by implant and material charges exhibited a downward trend. However, there were apparent sociodemographic and hospital-related discrepancies of resource utilization. The observed statistics can lead to more efficient resource utilization of TKA in China.

Venous thromboembolism is rare after total hip and knee joint arthroplasty with long thromboprophylaxis in Finnish fast-track hospitals

INTRODUCTION

Pharmacological thromboprophylaxis effectively prevents venous thromboembolism (VTE) after total knee (TKA) and total hip arthroplasty (THA). Less is known about the influence of fast-track arthroplasty on VTE risk. We conducted a register-based study to determine the incidence of VTE after fast-track TKA and THA in Finland using long thromboprophylaxis.

MATERIALS AND METHODS

All primary TKAs and THAs operated during 2015-2016 in 3 fast-track hospitals were identified from the Finnish Arthroplasty Register. Pulmonary embolism (PE) and deep vein thrombosis (DVT) diagnosed in this patient cohort within 90 days of surgery were identified from the Finnish Hospital Discharge Register. The recommended length of thromboprophylaxis was 10 to 14 days for TKA and 28 days for THA during study period.

RESULTS

During the study period, 3 831 THAs, 4 394 TKAs and 286 bilateral TKAs (BTKAs) were performed. Of all these patients, 60% were females. Venous thromboembolism (VTE) incidence within 90 days of surgery was 0.3% (95% CI 0.2-0.4). These VTEs comprised 10 PEs and 15 DVTs. None of the VTE patients´ died within the 90-day period.

CONCLUSION

VTE incidence is low in Finnish fast-track TKA and THA patients with long thromboprophylaxis.

Isokinetic knee muscle strength comparison after enhanced recovery after surgery (ERAS) versus conventional setup in total knee arthroplasty (TKA): a single blinded prospective randomized study

PURPOSE

Total knee arthroplasty (TKA) combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate isokinetic knee muscle strength after cemented TKA in combination with an enhanced recovery after surgery (ERAS) compared to a conventional setup.

METHODS

In the single blinded prospective randomized study, 52 patients underwent navigated primary cemented TKA within an ERAS (n = 30) or a conventional setup (n = 22). Preoperatively, five days and four weeks after surgery isokinetic knee muscle strength with BIODEX-type measuring device (peak torque in Nm, work in Joules and power in Watt) and subjective patient-related outcome measures (PROMs) were investigated.

RESULTS

The ERAS group showed significantly better outcomes in knee flexion at 180°/s (peak torque (Nm) p = 0.047, work (J) p = 0.040 and power (W) p = 0.016) 5 days postoperatively. The isokinetic measuring at knee extension 60°/s and 180°/s demonstrated no significant difference. The PROMs showed that patients were satisfied with the postoperative results in both groups. After 4 weeks, there was no longer a significant difference in isokinetic measuring at knee extension and flexion between the ERAS and conventional group.

CONCLUSIONS

TKA with the concept of ERAS improves excellent isokinetic outcome and patient satisfaction. The isokinetic muscle strength measurement can help patients and surgeons to modify expectations and improve patient satisfaction.

Preoperative Patient Expectation of Discharge Planning is an Essential Component in Total Knee Arthroplasty

Purpose

A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS).

Material and methods

This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated.

Results

In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge.

Conclusion

Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.

Effectiveness of Gamification in Knee Replacement Rehabilitation: Protocol for a Randomized Controlled Trial With a Qualitative Approach

BACKGROUND

Exergames can provide encouraging exercise options. Currently, there is limited evidence regarding home-based exergaming in the postoperative phase of total knee replacement (TKR).

OBJECTIVE

This study aimed to investigate the effects of a 4-month postoperative home-based exergame intervention with an 8-month follow-up on physical function and symptoms among older persons undergoing TKR compared with home exercise using a standard protocol. In addition, a concurrent embedded design of a mixed methods study was used by including a qualitative component within a quantitative study of exergame effects.

METHODS

This was a dual-center, nonblinded, two-arm, parallel group randomized controlled trial with an embedded qualitative approach. This study aimed to recruit 100 patients who underwent their first unilateral TKR (aged 60-75 years). Participants were randomized to the exergame or standard home exercise arms. Participants followed a custom-made exergame program independently at their homes daily for 4 months. The primary outcomes at 4 months were function and pain related to the knee using the Oxford Knee Score questionnaire and mobility using the Timed Up and Go test. Other outcomes, in addition to physical function, symptoms, and disability, were game user experience, exercise adherence, physical activity, and satisfaction with the operated knee. Assessments were performed at the preoperative baseline and at 2, 4, and 12 months postoperatively. Exergame adherence was followed from game computers and using a structured diary. Self-reported standard exercise was followed for 4 months of intervention and physical activity was followed for 12 months using a structured diary. Qualitative data on patients' perspectives on rehabilitation and exergames were collected through laddering interviews at 4 and 12 months.

RESULTS

This study was funded in 2018. Data collection began in 2019 and was completed in January 2022. The COVID-19 pandemic caused an unavoidable situation in the study for recruitment, data collection, and statistical analysis. As of November 2020, a total of 52 participants had been enrolled in the study. Primary results are expected to be published by the end of 2022.

CONCLUSIONS

Our study provides new knowledge on the effects of postoperative exergame intervention among older patients with TKR. In addition, this study provides a new understanding of gamified postoperative rehabilitation, home exercise adherence, physical function, and physical activity among older adults undergoing TKR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03717727; https://clinicaltrials.gov/ct2/show/NCT03717727.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/38434.

Perioperative Use of Antifibrotic Medications Associated With Lower Rate of Manipulation After Primary TKA: An Analysis of 101,366 Patients

BACKGROUND

Several commonly prescribed medications have known antifibrotic properties and have been shown to reduce postoperative scar formation in other clinical areas, but it is unknown whether the use of such medications perioperatively in patients undergoing TKA may improve rates of postoperative stiffness.

METHODS

A large US employer-sponsored healthcare database (Truven Marketscan) was queried for patients who underwent elective primary TKA for primary osteoarthritis between 2015-2019. Demographic information and comorbidities were recorded, along with whether patients were prescribed one of several medications with known antifibrotic properties during the three months before or after surgery.

RESULTS

Complete data were available for 101,366 patients undergoing TKA, of which 4,536 underwent MUA (4.5%). Perioperative use of any antifibrotic medication was associated with a lower likelihood of undergoing MUA (P < .001). When controlling for age, sex, comorbidities, opioid use, length of stay, among other variables, perioperative use of specific ACE inhibitors (OR 0.91, CI 0.84-1, P = .042), COX-2 inhibitors (OR 0.88, CI 0.81-0.96, P = .002), and angiotensin II receptor blockers, specifically losartan (OR 0.80, CI 0.70-0.91, P = .007) all remained significantly associated with lower rates of MUA.

CONCLUSION

This study, spanning over a hundred thousand primary TKA procedures over a recent five-year period, demonstrates an association between perioperative use of specific medications with antifibrotic properties and a decreased rate of MUA. These data will help inform future studies aimed to prospectively evaluate the potential of antifibrotic medications in preventing postoperative stiffness in high-risk patients undergoing knee arthroplasty.

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

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

[Results and lessons learned in fast-track arthroplasty]

BACKGROUND

Fast-track concepts in arthroplasty are understood as programs to optimize and homogenize perioperative procedures. With few exceptions, the literature reports a reduction in hospitalization time, a decrease in mortality and complications, earlier mobilization, and increased patient satisfaction through fast-track programs.

IMPLEMENTATION

The implementation of a fast-track concept requires the involvement and motivation of the entire treatment team, as the implementation of only individual components of a fast-track program does not lead to the desired goal. Country-specific regulations must be taken into account when evaluating fast-track programs. In particular, long-term results are also lacking.

OUTLOOK

For Germany, a scientific review is still pending. Modified perioperative measures but also a shortening of an inpatient stay must not reduce the currently existing high quality of care in arthroplasty. A possible reduction in the length of inpatient stay implies a compression, but not necessarily a reduction in the perioperative care required for a patient. For this reason, the surrounding conditions must also be created at a political level in the future to enable the achievement of the desired high quality.

Rapid rise in prevalence of knee replacements and decrease in revision burden over past 3 decades in Finland: a register-based analysis

BACKGROUND AND PURPOSE

The prevalence of knee joint replacements (KJR) has been less investigated in situations where the increase in incidence is known. This study investigated the annual and population-based prevalence of KJR and the relationship between the prevalence of KJRs and the incidence of revision surgery.

PATIENTS AND METHODS

All KJRs performed between 1980 and 2020 were identified from the Finnish Arthroplasty Register (FAR). KJR revisions and removals were extracted from the FAR and hospital discharge registers and patient deaths from Finnish Digital and Population Data Services Agency. We analyzed the annual prevalence by dividing the number of KJR survivors by the population aged 40 or older. The revision burden factor (RBF) was determined by dividing the annual number of revisions by the number of primary and revision KJRs in the population. Proportions of bilateral implants and patients with older KJRs performed 10 or more years earlier were identified.

RESULTS

KJR prevalence in Finland increased by 298% between 2000 and 2020, reaching 4.0% in 2020. The proportion of patients with bilateral KJRs and those with older KJRs had increased to 37% and 34%, respectively, by 2020. The annual RBF decreased statistically significantly from 1.9% to 0.7% between 1996 and 2020 (proportion ratio, PR 0.37 [95% CI 0.33-0.42]) and was higher among males (PR 1.23 [CI 1.20-1.26]).

INTERPRETATION

Although the recent rapid increase in KJRs is abating and the RBF is diminishing, it is important to take the continuing increase in the prevalence of KJRs into account when assessing hospitals' future resources.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Low incidence of clinically relevant bleeding complications after fast-track arthroplasty: a register study of 8,511 arthroplasties

BACKGROUND AND PURPOSE

Fast-track total joint replacement (TJR) has become increasingly common. Routine thromboprophylaxis for pulmonary embolism and deep venous thrombosis prevention lasts from 2 to 5 weeks. This retrospective registry study focused on clinically relevant bleeding complications 90 days after fast-track primary TJR.

PATIENTS AND METHODS

All primary fast-track total hip (THA) and knee arthroplasties (TKA) performed between 2015 and 2016 were extracted from the Finnish Arthroplasty Register and Finnish Hospital Discharge Register. Type of arthroplasty and indication for the operation were combined with diagnoses of clinically relevant bleeding complications within 90 days of surgery. The incidence of these bleedings was the primary outcome measure.

RESULTS

Of the total of 8,511 patients (mean age 67 years (SD 10); 60% female), 45% underwent unilateral THA, 52% unilateral TKA, and 3% bilateral TKA. The incidence of clinically relevant bleeding complications within 90 days was 1% (95% CI 0.8-1.3). No difference was observed in bleeding incidence between the groups. The 87 bleedings comprised 57 operative site bleedings, 17 gastrointestinal bleedings, 6 intracranial non-traumatic bleedings, 5 bleedings from the nose or another undetermined site, and 2 intraocular bleedings. 1 death due to intracranial bleeding was recorded, and hence clinically relevant bleeding-specific 90-day mortality was 0.01%.

INTERPRETATION

The incidence of clinically relevant bleeding complications was low. However, they cause patient discomfort, increase the use of healthcare services, and can be life-threatening and even fatal.

Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly

The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.

The Effect of Preoperative Education Prior to Hip or Knee Arthroplasty on Immediate Postoperative Outcomes

There is ample research demonstrating improved patient outcomes when using an enhanced recovery program. However, the literature reporting the impact of preoperative education alone prior to hip and knee arthroplasty is conflicting. With the number of these surgical procedures expected to increase in the next few years, the identification of strategies that positively impact outcomes is important. The aim of this study was to evaluate immediate postoperative physical therapy (PT) performance following a total hip or knee arthroplasty in patients who attended a preoperative education class compared with those who did not. This study was a retrospective chart review of 707 hip and knee arthroplasty patients, comparing outcomes based on preoperative educational session attendance. Demographics, comorbidities, length of stay (LOS), discharge disposition, and PT performance were collected from the chart review. Patients who attended the preoperative education class had significantly greater ambulation distances (p < .001), greater degrees of knee flexion (p < .001), and greater degrees of hip flexion (p = .012) on postoperative Day 1. Both hip (p < .001) and knee (p < .001) patients who attended the class had a significantly shorter LOS. The cost benefit analysis indicated a savings of $921.57 in direct costs per knee arthroplasty in those who attended a class. Patients who received preoperative education had greater mobility in the immediate postoperative period and reduced LOS for both hip and knee arthroplasties. Based on this study's results, preoperative education is effective in improving outcomes and reducing the cost of hip and knee arthroplasties.

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis

PURPOSE

This systematic review and dose-response meta-analysis aimed to investigate the relationship between hospital volume and outcomes for total knee arthroplasty (TKA).

METHODS

MEDLINE, Embase, CENTRAL and CINAHL were searched up to February 2020 for randomised controlled trials and cohort studies that reported TKA performed in hospitals with at least two different volumes and any associated patient-relevant outcomes. The adjusted effect estimates (odds ratios, OR) were pooled using a random-effects, linear dose-response meta-analysis. Heterogeneity was quantified using the I²-statistic. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively.

RESULTS

A total of 68 cohort studies with data from 1985 to 2018 were included. The risk of bias for all outcomes ranged from moderate to critical. Higher hospital volume may be associated with a lower rate of early revision ≤ 12 months (narrative synthesis of k = 7 studies, n = 301,378 patients) and is likely associated with lower mortality ≤ 3 months (OR = 0.91 per additional 50 TKAs/year, 95% confidence interval [0.87-0.95], k = 9, n = 2,638,996, I² = 51%) and readmissions ≤ 3 months (OR = 0.98 [0.97-0.99], k = 3, n = 830,381, I² = 44%). Hospital volume may not be associated with the rates of deep infections within 1-4 years, late revision (1-10 years) or adverse events ≤ 3 months. The confidence in the cumulative evidence was moderate for mortality and readmission rates; low for early revision rates; and very low for deep infection, late revision and adverse event rates.

CONCLUSION

An inverse volume-outcome relationship probably exists for some TKA outcomes, including mortality and readmissions, and may exist for early revisions. Small reductions in unfavourable outcomes may be clinically relevant at the population level, supporting centralisation of TKA to high-volume hospitals.

LEVEL OF EVIDENCE

III.

REGISTRATION NUMBER

The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019131209 available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131209 ).

Implementation of a rapid recovery protocol in total knee arthroplasty. A randomized controlled trial

BACKGROUND

Rapid recovery (RP) in total knee arthroplasty may increase the functionality while reducing costs. The aim of this study is to prove the benefits of a rapid recovery program compared to our classic protocol.

PATIENTS AND METHODS

We performed a RCT (NCT03823573) in patients undergoing otal knee arthroplasty. Intervention group (RP protocol) received local infiltration of levo-bupivacaine in the periarticular tissue and supervized ambulation 4-6h after surgery. Control (C) group received a femoral nerve block with levo-bupivacaine, while a drain was used. Ambulation after its removal. All the patients completed an Oxford Knee Score prior to surgery and 6 months after discharge. An ecodoppler to assess the presence of deep vein thrombosis was made one month after discharge. Minimum follow-up was of 6 months.

RESULTS

A total of 175 patients were included in the trial (92 patients in the control group, 83 patients in the RP group). There were no differences in sex, age, implanted prosthesis, hemoglobin drop, need for transfusion, range of motion on discharge (C: 82.6°, RP: 85°) and at the end of the follow-up (C: 105.1, RP: 106.6), Oxford Knee Score improvement (C: 17.5 points; RP: 19.3 points), patient satisfaction or re-admissions at the emergency department (C: 7.6%; RP: 10.8%). Significancy was found on time of ischemia (C: 81.29min; RP: 85.35min; P=0.03), need for morphine shots (C: 19.7%; RP: 38.6%; P=0.007), hospital stay (C: 3.84 days; RP: 2.54 days, P<0.0001) and time until ambulation (C: 2.46 days; RP: 0.23 days; P<0.0001).

CONCLUSION

Rapid recovery protocols can reduce hospital stay without increasing complications or need for re-admission.

Implementing fast track surgery in hip and knee arthroplasty using the lean Six Sigma methodology

Purpose

One of the biggest challenges in the health sector is that of costs compared to economic resources and the quality of services. Hospitals register a progressive increase in expenditure due to the aging of the population. In fact, hip and knee arthroplasty surgery are mainly due to primary osteoarthritis that affects the elderly population. This study was carried out with the aim of analysing the introduction of the fast track surgery protocol, through the lean Six Sigma, on patients undergoing knee and hip prosthetic replacement surgery. The goal was to improve the arthroplasty surgery process by reducing the average length of stay (LOA) and hospital costs

Design/methodology/approach

Lean Six Sigma was applied to evaluate the arthroplasty surgery process through the DMAIC cycle (define, measure, analyse, improve and control) and the lean tools (value stream map), adopted to analyse the new protocol and improve process performance. The dataset consisted of two samples of patients: 54 patients before the introduction of the protocol and 111 patients after the improvement. Clinical and demographic variables were collected for each patient (gender, age, allergies, diabetes, cardiovascular diseases and American Society of Anaesthesiologists (ASA) score).

Findings

The results showed a 12.70% statistically significant decrease in LOS from an overall average of 8.72 to 7.61 days. Women patients without allergies, with a low ASA score not suffering from diabetes and cardiovascular disease showed a significant a reduction in hospital days with the implementation of the FTS protocol. Only the age variable was not statistically significant.

Originality/value

The introduction of the FTS in the orthopaedic field, analysed through the LSS, demonstrated to reduce LOS and, consequently, costs. For each individual patient, there was an economic saving of € 445.85. Since our study takes into consideration a dataset of 111 patients post-FTS, the overall economic saving brought by this study amounts to €49,489.35.

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

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

The effect of pre-operative high doses of methylprednisolone on pain management and convalescence after total hip replacement in elderly: a double-blind randomized study

Purpose

The aim of the study was to assess whether administration of a single dose of methylprednisolone in the group patients above 65 years of age will be effective in complex analgesic management after total hip arthroplasty (THA).

Methods

Seventy-seven patients above 65 years old were double-blind randomized into two: the study and controls groups. Pre-operatively, the study group received as a single dose of 125 mg intravenous methylprednisolone, while the others saline solution as placebo. Peri-operatively, all the patients were administered opioid and nonopioid analgesic agents. We measured the levels of inflammatory markers (leukocytosis, C-reactive protein—CRP), pain intensity level (visual analog scale—VAS; numerical rating scale—NRS), the life parameters, and noted complications.

Results

Following administration of methylprednisolone were significantly lower levels of CRP on all the four post-operative days; leukocytosis on the second day; the VAS/NRS score at rest after six, 12, and 18 hours post-operatively, diminished the dose of parenteral opioid preparations (oxycodone hydrochloride), the duration of analgesia by peripheral nerve block was significantly higher as compared with the placebo group (p < 0.000001). No infectious complications were noted; there was one patient who developed post-operative delirium.

Conclusion

A single dose of methylprednisolone significantly reduces the level of post-operative pain at rest on the day of THA in the group patients above 65 years of age, decreases the dose of opioid analgesic agents, and significantly decreases the level of inflammatory markers, without infectious processes.

The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis

BACKGROUND

Use of platelet-rich-plasma (PRP) injections for treating knee osteoarthritis has increased over the past decade. We used cost-effectiveness analysis to evaluate the value of PRP in delaying the need for total knee arthroplasty (TKA).

METHODS

We developed a Markov model to analyze the baseline case: a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis undergoing a series of 3 PRP injections with a 1-year delay to TKA versus a TKA from the outset. Both health-care payer and societal perspectives were included. Transition probabilities were derived from systematic review of 72 studies, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry, and individual costs from Medicare reimbursement schedules. Primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs) and evaluated against willingness-to-pay thresholds of $50,000 and $100,000. One and 2-way sensitivity analyses were performed as well as a probabilistic analysis varying PRP-injection cost, TKA delay intervals, and TKA outcomes over 10,000 different simulations.

RESULTS

From a health-care payer perspective, PRP resulted in 14.55 QALYs compared with 14.63 for TKA from the outset, with total health-care costs of $26,619 and $26,235, respectively. TKA from the outset produced a higher number of QALYs at a lower cost, so it dominated. From a societal perspective, PRP cost $49,090 versus $49,424 for TKA from the outset. The ICER for TKA from the outset was $4,175 per QALY, below the $50,000 willingness-to-pay threshold. Assuming the $728 published cost of a PRP injection, no delay time that was <10 years produced a cost-effective course. When the QOL value was increased from the published value of 0.788 to >0.89, PRP therapy was cost-effective with even a 1-year delay to TKA.

CONCLUSIONS

When considering direct and unpaid indirect costs, PRP injections are not cost-effective. The primary factor preventing PRP from being cost-effective is not the price per injection but rather a lack of established clinical efficacy in relieving pain and improving function and in delaying TKA. PRP may have value for higher-risk patients with high perioperative complication rates, higher TKA revision rates, or poorer postoperative outcomes.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Mental Simulation Practice Has Beneficial Effects on Patients' Physical Function Following Lower Limb Arthroplasty: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the effectiveness of mental simulation practice (MSP) on measures of physical function recovery in patients who have undergone a joint replacement surgery of lower limbs.

DATA SOURCES

A systematic review was conducted using CINAHL, PubMed/MEDLINE, Embase, SPORTDiscus, PEDro, Cochrane Register of Controlled Trials, and Google Scholar from the earliest record until August 16, 2019.

STUDY SELECTION

The following inclusion criteria were used to determine eligibility for studies: (1) randomized and matched controlled trials recruiting men and women who underwent primary unilateral joint arthroplasty; (2) the study examined the effects of MSP intervention on measures of physical function recovery (both performance-based and patient self-reported); and (3) measures of interest were compared between MSP and control groups. A total of 8 papers (7 studies) met the inclusion criteria and were included.

DATA EXTRACTION

Data were extracted by 1 reviewer and checked by a second reviewer, independently.

DATA SYNTHESIS

When compared with standard physical therapy (SPT), MSP showed an effect on physical function in general (effect size [ES], 0.67; 95% confidence interval [CI], 0.38-0.96; n=7), maximal voluntary strength of knee extensor muscles of the affected leg (ES, 1.41; 95% CI, 0.64-2.18; n=2), brisk walking speed (ES, 1.20; 95% CI, 0.58-1.83; n=2), brisk walking speed with dual task (ES, 1.02; 95% CI, 0.41-1.63; n=2), timed up-to go test (ES, 0.96; 95% CI, 0.15-1.77; n=3), and active flexion of the affected leg (ES, 0.70; 95% CI, 0.29-1.11; n=4). Finally, meta-regression analysis revealed that the effects of MSP were significantly predicted only by total number of training sessions per study.

CONCLUSIONS

The present meta-analysis demonstrated that MSP intervention has multiple positive effects on measures of physical function recovery in patients who have undergone total knee or hip replacement surgery in comparison with SPT. Thus, MSP can be applied as an effective complementary therapy to SPT in physical rehabilitation of this specific population, especially in the early postacute and acute phase.

A cost-effectiveness analysis after implementation of a fast-track protocol for total knee arthroplasty

BACKGROUND

Since the introduction of arthroplasty fast-track protocols, many studies have investigated their effect on complications and length of hospital stay. However, few fast-track studies have examined the long-term effects on cost and health-related quality of life after total knee arthroplasty (TKA). This study aimed to specifically analyze, after implementation of fast-track TKA, cost-effectiveness with functional outcome, length of stay, thromboembolic complications, medical costs, and quality of life after 12 months.

METHODS

A retrospective cohort of 403 TKA patients treated by a fast-track pathway were compared with 283 patients in a non-fast-track pathway. Length of stay and thromboembolic complications were registered postoperatively. Healthcare costs were based on hospital production costs and calculated on average. Costs were compared with EQ-5D questionnaires to derived quality-adjusted life year (QALY) scores.

RESULTS

No between-protocol differences were found in functional outcome and quality of life after TKA. The fast-track protocol reduced the length of stay from a median five days to median three days, and did not influence the thromboembolic complication rate (2.6%). After one-year follow-up for fast-track pathway patients, QALY was 0.85 vs. 0.84 for non-fast-track. A reduction of 268,- euro per patient was calculated in favor of the fast-track protocol.

CONCLUSION

Fast-track protocol implementation is a cost-effective strategy for patients undergoing TKA, with high QALY and reduced costs. Fast-track TKA treatment is safe, with low thromboembolic complications. This is the first study to measure fast-track implementation effects on functional outcome and quality of life up to 12 months postoperatively, and calculate equivalent QALYs for both groups.

LEVEL OF EVIDENCE

Level III.

[Challenges of fast-track arthroplasty in Germany]

BACKGROUND

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

REASONS

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

SOLUTIONS

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

Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty?

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference.

RESULTS

Overall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05).

CONCLUSION

Approximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed.

LEVEL OF EVIDENCE

III.

Venous Thromboembolism Rates Did Not Decrease in Lower Extremity Revision Total Joint Arthroplasty From 2008 to 2016

BACKGROUND

In revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis [DVT] and/or pulmonary embolism [PE] in the same patient), DVT, PE, and mortality in the 30-day period after rTKA and rTHA.

METHODS

We identified 30,406 rTKA and rTHA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest.

RESULTS

The overall incidences of 30-day VTE, DVT, PE, and mortality for rTKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in rTHA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period.

CONCLUSION

Within 30 days of surgery, approximately 1 in 83 rTKA patients and 1 in 100 rTHA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in rTKA and rTHA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in rTHA and rTKA.

Manipulation under anesthesia after primary knee arthroplasty in Sweden: incidence, patient characteristics and risk of revision

Background and purpose - The incidence of manipulation under anesthesia (MUA) after knee arthroplasty surgery has been reported to vary between 0.5% and 10%. We evaluated the incidence of MUA after primary knee arthroplasty in Sweden, the demographics of the patients and the risk of revision. Patients and methods - Between 2009 and 2013, 64,840 primary total and unicompartmental knee arthroplasties (TKA and UKA) were registered in the Swedish Knee Arthroplasty Register (SKAR). MUAs performed between 2009 and 2014 were identified through the in- and outpatient registers of the Swedish National Board of Health and Welfare. Pertinent data were verified through medical records and patient demographics and revisions were obtained from the SKAR. Results - 1,258 MUAs were identified. Of these, 1,078 were 1st-time MUAs, performed within 1 year after the primary knee arthroplasty. The incidence of MUA was 1.7% and the incidence varied between hospitals from 0% to 5%. The majority were performed after TKA (98%), in younger patients (65% < 65 years), women (64%), and relatively healthy persons (88% had ASA ≤ 2). The cumulative risk of revision at 10 years was 10% (95% CI 8.6-12), similar for men and women. Interpretation - In Sweden, MUA is a rather uncommon measure after knee arthroplasty, especially after UKA. The CRR at 10 years was doubled compared to the general knee arthroplasty population. The frequency of the procedure varies between hospitals but in general it is performed more frequently in healthier and younger patients.

Reasons and Risk Factors for Delayed Discharge After Total Knee Arthroplasty Using an Opioid-Sparing Discharge Protocol

BACKGROUND

In this study, we aimed to assess the length of hospital stay after total knee arthroplasty in a European healthcare setting. We also aimed to investigate risk factors and reasons for delayed discharge when using an opioid-sparing fast-track protocol.

METHODS

From our institutional database, we retrospectively identified all primary elective unilateral total knee arthroplasties performed during January to December 2015. Both patient-related and surgery-related variables were collected from our databases. Risk factors were analyzed using multivariable logistic regression analysis.

RESULTS

The median length of stay (LOS) was 3 days. Independent risk factors for delayed discharge were higher age, higher American Society of Anesthesiologists score, general anesthesia, surgery performed toward the end of the week, longer duration of surgery, longer stay in the post-anesthesia care unit, and shorter preoperative walking distance. The main reasons for delayed discharge were delayed functional recovery and pain.

CONCLUSION

This study identified several independent risk factors for an LOS longer than 3 days. These risk factors add to the current knowledge on which patients have an increased risk of prolonged LOS, and which patients should be targeted when striving to further reduce the LOS.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors.

METHODS

Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms "total knee arthroplasty" and "length of stay". Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (RevMan) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014).

RESULTS

A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference [MD] = 0.81; 95% confidence interval [CI] = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98).

CONCLUSION

This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative "fast-track" programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications.

LEVEL OF EVIDENCE

IV, systematic review, and meta-analysis of level III and IV evidence.

The Main Predictors of Length of Stay After Total Knee Arthroplasty: Patient-Related or Procedure-Related Risk Factors

BACKGROUND

Often, differences in length of stay after total knee arthroplasty are solely attributed to patient factors. Therefore, our aim was to determine the influence of patient-related and procedure or structural-related risk factors as predictors of length of stay after total knee arthroplasty.

METHODS

A prospective cohort of 4,509 patients (54.6% of whom had Medicare for insurance) underwent primary total knee arthroplasty across 4 facilities in a single health-care system (from January 1, 2016, to September 30, 2017). Risk factors were categorized as patient-related risk factors (demographic characteristics, smoking status, Veterans RAND 12 Item Health Survey Mental Component Summary score [VR-12 MCS], Charlson Comorbidity Index, surgical indication, Knee injury and Osteoarthritis Outcome Score [KOOS], deformity, range of motion, and discharge location probability assessed by a nomogram predicting location after arthroplasty) or as procedure or structural-related risk factors (hospital site, surgeon, day of the week when the surgical procedure was performed, implant type, and surgical procedure start time). Multivariable cumulative link (proportional odds logistic regression) models were built to identify significant predictors from candidate risk factors for 1-day, 2-day, and ≥3-day length of stay. Performance was compared between a model containing patient-related risk factors only and a model with both patient-related and procedure or structural-related risk factors, utilizing the Akaike information criterion (AIC) and internally validated concordance probabilities (C-index) for discriminating a 1-day length of stay compared with >1-day length of stay.

RESULTS

Patient-related risk factors were significant predictors of length of stay (p < 0.05). A longer length of stay was predicted by older age, higher body mass index (BMI), higher Charlson Comorbidity Index, lower VR-12 MCS, and female sex. However, when the procedure or structural factors were added to the patients' risk factors, the AIC decreased by approximately 1,670 units. This indicates that procedure or structural-related risk factors provide clinically relevant improvement in explaining length of stay in addition to patient-related risk factors.

CONCLUSIONS

Despite patient-related factors such as age, sex, and comorbidities providing substantial predictive value for length of stay after total knee arthroplasty, the main driving predictors of single-day length of stay after total knee arthroplasty were procedure or structural-related factors, including hospital site and surgeon. Understanding the risk factors that affect outcomes after total knee arthroplasty provides the opportunity to influence and potentially modify them favorably to optimize care.

Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To evaluate the effects of enhanced recovery after surgery (ERAS) on the postoperative recovery of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

The PubMed, Embase, Cochrane and ISI Web of Science databases were searched to identify literature including randomised controlled trials (RCTs), cohort studies and case-control studies through 2 May 2018. The analysed outcomes were mortality rate, transfusion rate, range of motion (ROM), 30-day readmission rate, postoperative complication rate and in-hospital length of stay (LOS).

RESULTS

A total of 25 studies involving 16 699 patients met the inclusion criteria and were included in the meta-analysis. Compared with conventional care, ERAS was associated with a significant decrease in mortality rate (relative risk (RR) 0.48, 95% CI 0.27 to 0.85), transfusion rate (RR 0.43, 95% CI 0.37 to 0.51), complication rate (RR 0.74, 95% CI 0.62 to 0.87) and LOS (mean difference (MD) -2.03, 95% CI -2.64 to -1.42) among all included trials. However, no significant difference was found in ROM (MD 7.53, 95% CI -2.16 to 17.23) and 30-day readmission rate (RR 0.86, 95% CI 0.56 to 1.30). There was no significant difference in complications of TKA (RR 0.84, 95% CI 0.34 to 2.06) and transfusion rate in RCTs (RR 0.66, 95% CI 0.15 to 2.88) between the ERAS group and the control group.

CONCLUSIONS

This meta-analysis showed that ERAS significantly reduced the mortality rate, transfusion rate, incidence of complications and LOS of patients undergoing TKA or THA. However, ERAS did not show a significant impact on ROM and 30-day readmission rate. Complications after hip replacement are less than those of knee replacement, and the young patients recover better.

LEVEL OF EVIDENCE

Level 1.

Fast-tracking for total knee replacement reduces use of institutional care without compromising quality

Background and purpose - Fast-tracking shortens the length of the primary treatment period (length of stay, LOS) after total knee replacement (TKR). We evaluated the influence of the fast-track concept on the length of uninterrupted institutional care (LUIC) and other outcomes after TKR. Patients and methods - 4,256 TKRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast track (Hospital A) and non-fast track (Hospitals B, C and D). We analyzed length of uninterrupted institutional care (LUIC), LOS, discharge destination, readmission, revision, manipulation under anesthesia (MUA) and mortality rate in each hospital. We compared these outcomes for TKRs performed in Hospital A before and after fast-track implementation and we also compared Hospital A outcomes with the corresponding outcomes for the other 3 hospitals. Results - After fast-track implementation, median LOS in Hospital A fell from 5 to 3 days (p < 0.001) and (median) LUIC from 7 to 3 (p < 0.001) days. These reductions in LOS and LUIC were accompanied by an increase in the discharge rate to home (p = 0.01). Fast-tracking in Hospital A led to no increase in 14- and 42-day readmissions, MUA, revision or mortality compared with the rates before fast-tracking, or with those in the other hospitals. Of the 4 hospitals, LOS and LUIC were most reduced in Hospital A. Interpretation - A fast-track protocol reduces LUIC and LOS after TKR without increasing readmission, complication or revision rates.

Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up

INTRODUCTION

Fast-track protocols (FP) are used more and more to optimize results after total knee arthroplasty (TKA). Many studies evaluating FP in TKA concentrate on clinical outcome and medium to long-term results. Since discharge from hospital after TKA is achieved increasingly quicker worldwide using FP in an increasingly younger and active patient population, the effects of FP on functional outcome in the first days after TKA become more important. The purpose of the current study was to compare FP with a regular joint care protocol (RP), with an emphasis on the first 7 days after surgery.

MATERIALS AND METHODS

A non-blinded randomized controlled clinical pilot study was performed with 25 patients assigned to a FP group and 25 patients assigned to a RP group. Primary outcome was functional outcome, clinical outcome, pain, and complications for each day in the first week after surgery. Patients were followed up to 5 years after surgery.

RESULTS

Significantly lower VAS scores for knee pain, faster Timed-Up and Go test times and more mobility on functional tests were seen on several days in the first week in the FP group compared to the RP group. Few other significant differences were found at 2, 6 weeks, and no significant differences were found at 12 weeks and 1, 2 and 5 years after surgery.

CONCLUSIONS

Fast-track protocol for primary TKA showed significantly lower knee pain scores and improved functional outcome in the first 7 days after TKA compared to a regular protocol.