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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Day-case hip and knee arthroplasty: stages of care and the development of an institutional pathway

Day-case, or outpatient, arthroplasty is growing and has been adopted in healthcare systems because of its cost-effectiveness. A number of studies that reported on day-case total hip arthroplasty, total knee arthroplasty and unicompartmental knee arthroplasty have shown that they can be performed successfully in a select group of patients. However, safety remains a concern, as a clear pathway, including discharge criteria, is not well described in the literature. This article outlines the stages of care involved in day-case hip and knee arthroplasty and gives insights from University College London Hospital's own evidence-based day-case arthroplasty pathway.

Does rapid mobilisation as part of an enhanced recovery pathway improve length of stay, return to function and patient experience post primary total hip replacement? A randomised controlled trial feasibility study

PURPOSE

Day-zero ambulation may enable patients to recover and leave hospital quicker following total hip replacement (THR). The present randomised control feasibility study investigated the efficacy of day-zero ambulation as a physiotherapeutic intervention.

METHODS

Thirty-six non-blinded adults aged 44-85 (Mean 67.1; SD 9.6 years) undergoing primary, uncomplicated THR were block randomized to either a control group (n = 18) with standard post-operative physiotherapy or an intervention group (n = 18) incorporating walking on the same day as the operation. Outcomes were length of hospital stay (LOS), time to reach functional milestones and achieve all physiotherapy discharge criteria, post-operative pain scores, complications and patient experience.

RESULTS

Participants treated with day-zero ambulation had reduced median hospital LOS of 1 day (p = .096), and median reduced times to reaching functional milestones of 39.7 h quicker to transfer to a chair (p < .001), 24.5 h quicker to walk 10 m (p = .009) and 26.4 h quicker to independently ascend and descend stairs (p = .01). Participants in the intervention group were deemed physiotherapy ready to leave hospital significantly earlier than control group (1.04 days, p = .015).

CONCLUSIONS

Day-zero ambulation appears safe and may have clinically relevant effects in speeding patient functional recovery and facilitating earlier discharge from hospital. Implications for RehabilitationDay-zero ambulation following total hip replacement (THR) appears safe.Preliminary data suggest that day-zero mobilisation following THR could be efficacious and support the need for a fully powered randomised controlled trial.There may be a clinically relevant effect in speeding patient functional recovery and facilitating an earlier discharge from hospital.

Exploring treatment effect heterogeneity of a PROMs alert intervention in knee and hip arthroplasty patients: A causal forest application

Patient reported outcome measures (PROMs) experience an uptake in use for hip (HA) and knee arthroplasty (KA) patients. As they may be used for patient monitoring interventions, it remains unclear whether their use in HA/KA patients is effective, and which patient groups benefit the most. Nonetheless, knowledge about treatment effect heterogeneity is crucial for decision makers to target interventions towards specific subgroups that benefit to a greater extend. Therefore, we evaluate the treatment effect heterogeneity of a remote PROM monitoring intervention that includes ∼8000 HA/KA patients from a randomized controlled trial conducted in nine German hospitals. The study setting gave us the unique opportunity to apply a causal forest, a recently developed machine learning method, to explore treatment effect heterogeneity of the intervention. We found that among both HA and KA patients, the intervention was especially effective for patients that were female, >65 years of age, had a blood pressure disease, were not working, reported no backpain and were adherent. When transferring the study design into standard care, policy makers should make use of the knowledge obtained in this study and allocate the treatment towards subgroups for which the treatment is especially effective.

Evaluation of the changes in incidence and patient age of knee arthroscopy along with changes in time between knee arthroscopy and arthroplasty between 1998 and 2018: a nationwide register study

BACKGROUND

Recent evidence has led to guidelines to refrain from recommending knee arthroscopy for patients with an osteoarthritis diagnosis. The aim of this study was to evaluate the latest changes in the incidence of arthroscopic surgery for degenerative knee disease, changes in the ages of those patients and the delay between knee arthroscopy and arthroplasty, in Finland between 1998 and 2018.

METHOD

The data for were collected from the Finnish National Hospital Discharge Register (NHDR). All knee arthroplasties and arthroscopies performed due to osteoarthritis, degenerative meniscal tears, and traumatic meniscal tears were included. Incidence rates (per 100,000 person-years) as well as the median age of patients were calculated.

RESULTS

The incidence of arthroscopy decreased 74% (413 to 106 per 100,000 person-years) and knee arthroplasty increased 179% (94 to 262 per 100,000 person-years) between 1998 and 2018. The incidence of all arthroscopies increased until 2006. Subsequently, the incidence of arthroscopy due to OA decreased by 91% and arthroscopic partial meniscectomy (APM) for degenerative meniscal tears decreased by 77% until 2018. The decrease of traumatic meniscal tears begun later, leading to decrease of 57% between 2011 and 2018. Conversely, the incidence of patients undergoing APM of traumatic meniscal tear increased 375%. The median age of patients who underwent knee arthroscopy decreased from 51 to 46 and from 71 to 69 in knee arthroplasty patients.

CONCLUSIONS

Increasing evidence that recommends refraining from knee arthroscopy in OA and degenerative meniscal tears has led to a dramatic decrease in the incidence of arthroscopies. Simultaneously, the median age of the patients who undergo these operations has continued to decrease.

Use of a tourniquet is not associated with increased risk of venous thromboembolism after fast-track total knee arthroplasty: a prospective multicenter cohort study of 16,250 procedures

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) is a serious postoperative complication after total knee arthroplasty (TKA). Use of a tourniquet has shown conflicting results for risk of VTE after TKA. We aimed to investigate the associated risk of VTE after TKA using tourniquet in a fast-track set-up as no previous data exists.

PATIENTS AND METHODS

We performed an observational cohort study from 9 fast-track centers including unilateral primary TKA from 2010-2017 with prospective collection of preoperative risk-factors and complete 90-day follow-up. Use of a tourniquet was registered in the Danish Knee Arthroplasty Register. Postoperative VTE was identified from health records. We performed risk analyses using a mixed-effects logistic regression model adjusting for previously identified risk factors.

RESULTS

Of the 16,250 procedures (39% males, mean age 67.9 [SD 10.0] years, median LOS 2 [interquartile range 2-3]) 12,518 (77%) were performed with a tourniquet. The annual tourniquet usage varied greatly between departments from 0% to 100%, but also within departments from 0% to 99%. There was no significant difference between the 2 groups with 52 (0.42%) VTEs in the tourniquet group vs. 25 (0.67%) in the no-tourniquet group (p = 0.06 for cumulative 90-day incidence of VTE). This association remained statistically insignificant for VTE using tourniquet after adjustment for previously identified risk factors.

CONCLUSION

We found no association between the use of a tourniquet and increased risk of 90-day VTE after primary fast-track TKA, irrespective of the length of time for which the tourniquet was applied.

Complications after lateral unicompartmental knee arthroplasty in a fast-track setting: a prospective cohort study of 170 procedures

BACKGROUND AND PURPOSE

In existing studies on fasttrack unicompartmental knee arthroplasty (UKA), the majority of surgeries are medial. There are substantial differences between lateral and medial UKA, which is why outcomes cannot automatically be compared. To gain information on the feasibility and safety of fast-track protocols in lateral UKAs, we investigated length of stay (LOS) and early complications after lateral UKA, performed using a fast-track protocol in well-established fast-track centers.

PATIENTS AND METHODS

We retrospectively evaluated prospectively collected data on patients undergoing lateral UKA in a fast-track setup from 2010 to 2018 at 7 Danish fast-track centers. Data on patient characteristics, LOS, complications, reoperations, and revisions was analyzed using descriptive statistics. Safety and feasibility were defined as complication and reoperation rates within 90 days comparable to non-fast track lateral UKA or fast-track medial UKA.

RESULTS

We included 170 of patients with a mean age of 66 (SD 12) years. Median LOS was 1 day (interquartile range 1-1), which was unchanged from 2012-2018. 18% were discharged on the day of surgery. Within 90 days, 7 patients experienced medical complications and 5 patients experienced surgical complications. 3 patients underwent reoperation, 2 were soft tissue revisions and the third was removal of an exostosis due to catching of the patella. 1 patient was revised due to a bearing dislocation.

CONCLUSION

Our findings suggest that lateral UKA in a fast-track setting is feasible and safe.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative High Sleep Quality Predicts Further Decrease in Length of Stay after Total Joint Arthroplasty under Enhanced Recovery Short-stay Program: Experience in 604 Patients from a Single Team

Objective

To investigate the safety, efficiency and cost of total joint arthroplasty (TJA) under the enhanced recovery after surgery (ERAS) program and identify predictors facilitating further decrease in length of stay (LOS).

Methods

We retrospectively collected the information of patients who underwent primary unilateral TJA by a single surgical team between January 2017 and June 2019. A total of 604 patients with LOS ≤ 3 was enrolled in this study. All patients completed 12‐month or longer follow‐up. Patients received the same ERAS protocol, mainly including preoperative preparation (patient education, preoperative functional exercises, nutritional support), blood management, pain management, sleep management, prevention of infection, prevention of thrombosis and strict discharge criteria. Preoperative characteristics of patients were collected from the medical record system and were compared between the LOS ≤ 2 group and the LOS = 3 group. Factors with significant difference were included in multivariate logistic regression analysis to find independent preoperative predictors for LOS. Joint function at the latest follow‐up, adverse events rate and hospitalization costs were compared between the LOS ≤ 2 group and the LOS = 3 group.

Results

Of the enrolled 604 patients, 271 patients (44.9%) had a LOS of 2 days or less while 333 patients (55.1%) had a LOS of 3 days. Pittsburgh Sleep Quality Index score (odds ratio [OR] = 1.084, 95% confidence interval [CI] = 1.024–1.147, P = 0.005), preoperative albumin level (OR = 0.945, 95% CI = 0.905–0.988, P = 0.012), digestive diseases (OR = 1.084, 95% CI = 1.024–1.147, P = 0.005) and total hip arthroplasty (THA) (OR = 0.273, 95% CI = 0.170–0.439, P < 0.001) were predictors of LOS ≤ 2 in the multivariate logistic analysis model. The postoperative joint function scores and adverse event rates were comparable between the LOS ≤ 2 group and the LOS = 3 group. The hospital costs were lower in the LOS ≤ 2 group than the LOS = 3 group.

Conclusion

Under the rigorous ERAS program, 2‐day discharge in unselected TJA patients can be routinely applied. Patients with high preoperative sleep quality, high preoperative albumin level, free of digestive disease and undergoing THA procedure are more likely to be discharged within 2 days.

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.

Length of stay in patients undergoing total knee arthroplasty

Background

Minimizing costs associated with the care of patients undergoing total knee arthroplasty (TKA) can reduce the burden on health systems that regularly struggle with limited resources. Predicting and reducing TKA associated length of stay (LoS) can therefore be invaluable. This study aimed to determine the factors that impact LoS in patients undergoing TKA and propose a model design to predict LoS.

Methods

A retrospective study was performed on patients undergoing TKA in a tertiary teaching hospital. Patients who underwent TKA from March 2007 to March 2021 were included in the study. Data were extracted from available electronic and paper records. Variables evaluated included: patients' demographic data, general admission data, laboratory data, transfusion, operation data, and preoperative comorbidities and medical history. Independent T-test, one-way ANOVA, and Pearson correlation were used for univariate data analysis. For multivariate analysis and model designing, multiple regression stepwise methods were used.

Results

878 patients were included in this study. Mean LoS was 6.09 (SD = 1.83) with a median of 6 days. Factors found to have a significant effect on length of stay were age, revision surgery, Anesthesia type, intensive care unit admission, insurance, transfusion, preoperative hemoglobin level, and pre-operative platelet (Plt) count. Applying a multiple regression stepwise model to these variables showed that the following pre-operative factors can be predictive for LoS: revision surgery, sex, medical insurance, hemoglobin level, and Plt count.

Conclusions

It was deduced that sex, revision, pre-operative hemoglobin and Plt level and health insurance were the best predictors for LoS in patients undergoing TKA.

[Pain therapy and anaesthesiological procedures in fast-track arthroplasty]

Since the introduction of fast-track surgery in the field of arthroplasty, all disciplines involved have been challenged with the task of close and continuous joint communication in the context of daily routine care. Processes that have been agreed upon interdisciplinarily must be reviewed at regular intervals, and, if necessary, adapted and newly agreed upon with the aim of optimizing the perioperative risks both medically and along the therapeutic pathway. The responsibility of the anaesthesiologist is not only limited to the performance of anaesthesia, but also includes the care of patients with a view to optimal pain therapy, maintenance of homeostasis and ensuring a rapid return of the patient's self-determination.

Tempering Expectations for Outpatient Total Knee Arthroplasty for Patients Over 70

BACKGROUND

Total knee arthroplasty (TKA) is now considered an outpatient procedure, yet advanced age impacts patients' ability to achieve outpatient discharge. Therefore, the purpose of this study is to determine the rate of successful outpatient discharge for TKA patients above 70 years of age and identify potential barriers to success.

METHODS

This retrospective review included 352 unilateral TKA patients. The rapid discharge protocol was followed for all patients with the intention of discharge within a 24-hour period. Successful outpatient discharge was classified as ≤24-hour stay and failure was any stay exceeding a 24-hour period in the hospital. Univariate logistic regressions were performed to determine the influence of independent variables on discharge status for all patients and only patients >70 years old.

RESULTS

Overall, 46 patients (13%) failed to achieve outpatient discharge, with 35 (76%) patients being ≥70 years old. For patients ≥70, age was not a predictive variable for failure to achieve outpatient discharge (P = .484). However, being female (odds ratio 3.273, 95% confidence interval 1.286-8.325, P = .013) and the use of an assistive walking device (odds ratio 3.031, 95% confidence interval 1.387-6.625, P = .005) remained independent contributors to prolonged hospital stay.

CONCLUSION

With patients ≥70 years old more likely to require >24-hour stays, age should be an evaluated metric for justifying higher levels of reimbursement. Although TKA is now considered an outpatient procedure, greater consideration should be given to patients ≥70 years old for higher levels of reimbursement as outpatient discharge is less likely to be successful.

Enhanced Recovery after Surgery for Knee Arthroplasty in the Era of COVID-19

Enhanced recovery after surgery (ERAS) represents a paradigm shift in perioperative care, aimed at achieving early recovery for surgical patients, reducing length of hospital stay, and complications. The purpose of this study was to provide an insight of the impact of the COVID-19 on ERAS protocols for knee arthroplasty patients in a tertiary hospital and potential strategy changes for postpandemic practice. We retrospectively reviewed all cases that underwent surgery utilizing ERAS protocols in the quarter prior to the pandemic (fourth quarter of 2019) and during the first quarter of 2020 when the pandemic started. A review of the literature on ERAS protocols for knee arthroplasty during the COVID-19 pandemic was also performed and discussed. A total of 199 knee arthroplasties were performed in fourth quarter of 2019 as compared with 76 in the first quarter of 2020 during the COVID-19 outbreak. Patients who underwent surgery in the first quarter of 2020 had shorter inpatient stays (3.8 vs. 4.5 days), larger percentage of discharges by postoperative day 5 (86.8 vs. 74.9%), and a larger proportion of patients discharged to their own homes (68 vs. 54%). The overall complication rate (1.3 vs. 3%) and readmission within 30 days (2.6 vs. 2%) was similar between both groups. ERAS protocols appear to reduce hospital lengths of stay for patients undergoing knee arthroplasty without increasing the risk of short-term complications and readmissions. The beneficial effects of ERAS appear to be amplified by and are synchronous with the requirements of operating in the era of a pandemic.

Fast-track revision knee arthroplasty

BACKGROUND

Limited data exist on fast-track protocols in relation to revision knee arthroplasty. Hence, the aim of this study was to report length of stay (LOS), risk of LOS > 5 days and readmission ≤ 90 days after revision knee arthroplasty in centers with a well-established fast-track protocol in both primary and revision surgery.

METHODS

An observational cohort study from the Centre for Fast-track Hip and Knee Replacement and the Danish Knee Arthroplasty Register. We included elective aseptic major component revision knee arthroplasties consecutively from 6 dedicated fast-track centers from 2010 to 2018.

RESULTS

1439 revision knee arthroplasties were analyzed, including 900 total revisions, 171 large partial revisions (revision of either femoral or tibia component) and 368 revisions of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). Mean age was 65 years (SD 10.9) and 66% were females. Mean LOS was 3.7 days (SD 3.9) in the study period, but decreased to 2.4 days (SD 1.3) in 2018. Risk factors for LOS > 5 days was ≥ 1 previous revision, use of walking aid, BMI > 35, ages < 50, 70-79 and ≥ 80 years, whereas revision of UKA to TKA and large partial revision were negatively associated. The 90-day readmission and mortality risk was 9.1% and 0.5%. Cardiac disease and use of walking aid were associated with increased risk of readmission ≤ 90 days.

CONCLUSION

Elective aseptic major component revision knee arthroplasty using similar fast-track protocols as in primary TKA is safe with short and decreasing LOS.

Risk analysis of restrictive factors for fast-track hip arthroplasty - a retrospective study of 1138 patients

Fast track programs have been introduced to reduce perioperative complication rates and to quickly reintegrate the patient into everyday life. The aim of this retrospective case-control study was to identify patient characteristics and patient-independent factors that influence fast track programs in hip arthroplasty. A total of 1138 patients were examined. A hospital stay of more than seven days was used to define the case group. In addition to the causes for the longer hospitalisation, age, sex, BMI, chronic nicotine and alcohol abuse, ASA score, surgical duration, anaemia and blood transfusion as well as concomitant diseases were assessed. The statistical analysis included two-sample t-test, chi-square test and logistic regression analyses. An 95% confidence interval was calculated (p<0.05). 16.9% of patients could not leave the hospital on the seventh day. The main causes were delayed wound healing (69.4%), increased CRP (43.0%>100 mg/l), and internal complications (19.7%). At a mean of 69.2 ± 10.7 years, the age of the case group was significantly higher than that of the control group, which had a mean of 63.3 ± 10.3 years (p<0.001). Cardiac comorbidities (p<0.001), BMI (p=0.023), and alcohol consumption (p<0.001) increased the risk for longer hospitalisation. Significant patient-independent factors were duration of the surgery (p<0.001) and transfusion (p<0.001). Successful application of fast-track hip arthroplasty is possible for every patient. However, longer hospi- talisation and delayed discharge must be taken into account for patients with advanced age, cardiac comorbidities, alcohol consumption, and high BMI.

Influence of body mass index and age on day-of-surgery discharge, prolonged admission, and 90-day readmission after fast-track unicompartmental knee arthroplasty

Background and purpose - The indications for unicompartmental knee arthroplasty (UKA) have become less restrictive and, today, high age and high BMI are not considered contraindications by many surgeons. While the influence of these patient characteristics on total knee arthroplasty is well documented, evidence on UKA is lacking. We investigated the effect of BMI and age on day of surgery (DOS) discharge, prolonged admission, and 90-day readmission following UKA surgery.Patients and methods - This retrospective cohort study included 3,897 UKA patients operated on between 2010 and 2018 in 8 fast-track arthroplasty centers. Patients were divided into 5 BMI groups and 5 age groups. Differences between groups in the occurrence of DOS discharge, prolonged admission > 2 days, and 90-day readmission was investigated using a chi-square test and mixed-effect models adjusted for patient characteristics using surgical center as a random effect.Results - Median LOS was 1 day. DOS discharge was achieved in 26% of patients with no statistically significant differences between BMI groups. DOS discharge was less likely in UKA patients aged > 70 years (age 71-80; odds ratio [OR] 0.7 [95% CI 0.6-0.9]). Prolonged admission was not affected by BMI or age in the adjusted analysis. 90-day readmission was more likely in patients with BMI > 35 (OR 1.9 [CI 1.1-3.1]) and patients aged 71-80 (OR 1.5 [CI 1.1-2.1]).Interpretation - Age > 70 years decreased the likelihood of DOS discharge after UKA. High BMI as well as advanced age increased the likelihood of 90-day readmission. This should be noted by surgeons operating on patients with high BMI and age.

Fatal outcome and intensive care unit admission after total hip and knee arthroplasty: An analytic of preoperative frailty and comorbidities

BACKGROUND

With increasing demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), a higher percentage of patients are identified with comorbidities that might increase the risk of complications. We aimed to elucidate the preoperative characteristics of patients with a fatal outcome or admission to the Intensive Care Unit (ICU) within 90 days after THA or TKA. We arbitrarily hypothesized that more than 50% of those patients would be frail.

METHODS

This is a register based, explorative study including patients undergoing elective, unilateral, primary THA or TKA in the Capital Region of Denmark from 2010 to 2017, and who subsequently died or were admitted to the ICU within 90 days. The modified Frailty Index (mFI) was calculated from the medical records, and a score of ≥0.36 defined frailty.

RESULTS

A total of 33,758 patients underwent THA or TKA, and 284 patients (0.8%) died or were admitted to the ICU within 90 days. Fifty-seven patients (20%) were frail (95% CI 16.2-25.7%). The most common comorbidities were hypertension (63%) and pulmonary diseases (32%), and 56% used walking aids. Two or more comorbidities were present in 65% of patients, and 14% had no comorbidities at all.

CONCLUSION

Only 20% of patients with a fatal outcome or ICU admission after elective THA or TKA could be categorized as frail based on the mFI. Further studies with a prospective design are needed to clarify the mFI as a risk stratification tool in elderly multimorbid patients undergoing elective arthroplasty surgery.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures

BACKGROUND

Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration.

METHODS

We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients.

RESULTS

A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1-3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3-3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes.

CONCLUSIONS

Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Machine learning approaches in predicting ambulatory same day discharge patients after total hip arthroplasty

BACKGROUND

With continuing financial and regulatory pressures, practice of ambulatory total hip arthroplasty is increasing. However, studies focusing on selection of optimal candidates are burdened by limitations related to traditional statistical approaches. Hereby we aimed to apply machine learning algorithm to identify characteristics associated with optimal candidates.

METHODS

This retrospective cohort study included elective total hip arthroplasty (n=63 859) recorded in National Surgical Quality Improvement Program dataset from 2017 to 2018. The main outcome was length of stay. A total of 40 candidate variables were considered. We applied machine learning algorithms (multivariable logistic regression, artificial neural networks, and random forest models) to predict length of stay=0 day. Models' accuracies and area under the curve were calculated.

RESULTS

Applying machine learning models to compare length of stay=0 day to length of stay=1-3 days cases, we found area under the curve of 0.715, 0.762, and 0.804, accuracy of 0.65, 0.73, and 0.81 for logistic regression, artificial neural networks, and random forest model, respectively. Regarding the most important predictive features, anesthesia type, body mass index, age, ethnicity, white blood cell count, sodium level, and alkaline phosphatase were highlighted in machine learning models.

CONCLUSIONS

Machine learning algorithm exhibited acceptable model quality and accuracy. Machine learning algorithms highlighted the as yet unrecognized impact of laboratory testing on future patient ambulatory pathway assignment.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Length of Stay and 90-Day Readmission/Complication Rates in Unicompartmental Versus Total Knee Arthroplasty: A Propensity-Score-Matched Study of 10,494 Procedures Performed in a Fast-Track Setup

BACKGROUND

Whether to use unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) for appropriate osteoarthritis cases is a subject of debate. UKA potentially offers faster recovery and fewer short-term complications. However, reported differences in preoperative comorbidity between TKA and UKA-treated patients could affect outcomes. The aim of this study was to investigate differences in the length of the postoperative hospital stay (LOS) as well as readmissions and complications within 90 days after surgery between matched UKA and TKA cohorts.

METHODS

Patients undergoing UKA or TKA in a fast-track setup at 9 orthopaedic centers from 2010 to 2017 were included in the study. Propensity score matching with exact matching for surgical year was used to address differences in demographics and comorbidity between the UKA and TKA groups, resulting in a matched cohort of 2,786 patients who underwent UKA and 7,708 who underwent TKA. Univariable linear or logistic regression models, multivariable mixed-effects models, and a chi-square test were used to investigate differences in LOS, readmissions, and complications between the UKA and TKA groups.

RESULTS

The UKA group had a shorter median LOS than the TKA group (1 compared with 2 days, p < 0.001). The UKA group was more likely to be discharged on the day of surgery (21.1% compared with 0.5%, odds ratio [OR] = 38.5, 95% confidence interval [CI] = 27.0 to 52.6) and less likely to have an LOS of >2 days (OR = 0.20, 95% CI = 0.17 to 0.24) compared with the TKA group. There was no difference in the 90-day readmission rate (p = 0.611) between the groups. The UKA group had fewer periprosthetic joint infections (OR = 0.50, 95% CI = 0.26 to 0.99) and reoperations (OR = 0.40, 95% CI = 0.20 to 0.81) compared with the TKA group. However, aseptic revisions were more frequent in the UKA group (OR = 2.5, 95% CI = 1.1 to 6.0).

CONCLUSIONS

The UKA group had shorter hospital stays, a higher rate of discharge on the day of surgery, and fewer periprosthetic joint infections and reoperations compared with the matched TKA group. However, the TKA group had fewer aseptic revisions. Our findings support the use of UKA in a fast-track setup when indicated.

LEVEL OF EVIDENCE

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

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.

Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates

PURPOSE

With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes.

METHODS

Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted.

RESULTS

We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups.

CONCLUSION

ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways.

LEVEL OF EVIDENCE

Level II, Prospective comparative study.

Comparison of a fast track protocol and standard care after hip arthroplasty in the reduction of the length of stay and the early weight-bearing resumption: study protocol for a randomized controlled trial

BACKGROUND

To date, hip arthroplasty is one of the most commonly performed surgical procedures, with growing worldwide demand. In recent decades, major progress made in terms of surgical technique, biomechanics, and tribology knowledge has contributed to improve the medical and functional management of the patient. This study aims to assess if the application of a fast track protocol, consisting of a preoperative educational intervention, adequate postoperative pain control, and intensive rehabilitation intervention, reduces the length of stay (LOS) and allows the early functional recovery compared to standard clinical practice for patients undergoing hip arthroplasty.

METHODS

The study population consists of 90 patients with primary arthrosis of the hip with an anterior indication of hip arthroplasty. The exclusion criteria are older than 70 years, a contraindication to performing spinal anesthesia, and bone mass index (BMI) greater than 32. Participants, 45 for each group, are randomly allocated to one of two arms: fast track clinical pathway or standard care protocol. During allocation, baseline parameters such as Harris Hip Score (HHS) and Western Ontario and McMaster Universities (WOMAC) index are collected. On the third postoperative day, the functional autonomy for each patient is assessed by the Iowa Level of Assistance (ILOA) scale, and it is expected the discharge for patients in the fast track group (primary outcome). On the other hand, standard care patient discharge is expected after 5-7 days after surgery. During follow-up fixed at 6 weeks and 3, 6, and 12 months, HHS and WOMAC scores are collected for each patient (secondary outcomes).

DISCUSSION

Although total hip replacement has become a widespread standardized procedure, to the authors' knowledge, only few randomized controlled trials were performed to evaluate the effectiveness of fast track pathway vs. standard care procedure in the reduction of the LOS after hip arthroplasty. It is expected that our results collected by the application of minimally invasive surgical interventions with concomitant management of perioperative pain and bleeding and early functional rehabilitation will contribute to enriching the understanding of clinical and organizational aspects linked to fast track arthroplasty.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03875976 . Registered on 15 March 2019-"retrospectively registered".

Assessment of Psychological Factors in Short-Stay Total Hip Arthroplasty Protocol

BACKGROUND

Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol.

METHODS

We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol.

RESULTS

Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment.

CONCLUSION

Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization.

Influence of day of surgery and prediction of LOS > 2 days after fast-track hip and knee replacement

Background and purpose - Enhanced recovery programs have reduced length of stay (LOS) after hip and knee arthroplasty (THA/TKA). Although risk factors disposing to prolonged LOS are well documented, there is limited information on the role of weekday of surgery. This study analyzed the role of weekday of surgery and other potential risk factors for LOS > 2 days.Patients and methods - We included 10,576 unselected consecutive procedures between January 2016 and August 2017 within a multicenter fast-track THA/TKA collaboration with prospective collection of preoperative characteristics. We used multiple regression analysis of potential risk factors for LOS > 2 days followed by construction of a simple risk score from 0 to 15 points based on the calculated odds ratios.Results - Mean LOS was 1.9 (SD 1.8) days, with 80% of patients having surgery from Monday to Wednesday. Of these, 17% (95% CI 16-18) had a LOS > 2 days vs. 19% (CI 17-21) in those operated on Thursday and Friday. Patients were scheduled evenly throughout the week regardless of risk of LOS > 2 days and despite the fact that 38% (CI 35-40) of patients with ≥ 6 points (16% of the total population) had a LOS > 2 days compared with 14% (CI 13-14) in those with < 6 points. In these "high-risk" patients, the fraction with LOS > 2 days increased when having surgery on Thursdays or Fridays (43% CI 38-49) compared with Monday to Wednesday (37% CI 34-39).Interpretation - A detailed preoperative risk assessment may be helpful to plan the weekday of surgery in order to decrease LOS and weekend hospitalization.

To Predict the Length of Hospital Stay After Total Knee Arthroplasty in an Orthopedic Center in China: The Use of Machine Learning Algorithms

Background and Objectives: Total knee arthroplasty (TKA) is widely performed to improve mobility and quality of life for symptomatic knee osteoarthritis patients. The accurate prediction of patients' length of hospital stay (LOS) can help clinicians for rehabilitation decision-making and bed assignment planning, which thus makes full use of medical resources.

Methods: Clinical characteristics were retrospectively collected from 1,298 patients who received TKA. A total of 36 variables were included to develop predictive models for LOS by multiple machine learning (ML) algorithms. The models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance and decision curve analysis (DCA) for clinical values. A feature selection approach was used to identify optimal predictive factors.

Results: The areas under the ROC curve (AUCs) of the nine models ranged from 0.710 to 0.766. All the ML-based models performed better than models using conventional statistical methods in both ROC curves and decision curves. The random forest classifier (RFC) model with 10 variables introduced was identified as the best predictive model. The feature selection indicated the top five predictors: tourniquet time, distal femoral osteotomy thickness, osteoporosis, tibia component size, and post-operative values of Hb within 24 h.

Conclusions: By analyzing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA, and the RFC model performed the best.

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

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

Outcomes of outpatient total hip arthroplasty: a systematic review

INTRODUCTION

Similar to other total joint arthroplasty procedures, total hip arthroplasty (THA) is shifting to an outpatient setting. The purpose of this study was to analyse outcomes following outpatient THA.

METHODS

A comprehensive literature search was performed in April 2019 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Embase, and Cochrane databases to identify articles that reported functional outcomes following outpatient total hip arthroplasty (THA).

RESULTS

9 articles, with 683 hips and a collective study period of 1988 to 2016, were included in this analysis. The mean age across all studies was 58.9 years and the follow-up period ranged from 4 weeks to 10 years. 4 studies reported Harris Hip Scores (HHSs) for their patient populations and in 3 studies, the average HHSs were excellent (>90) by 6 weeks postoperatively. The fourth study reported fair HHS scores for the outpatient and inpatient THA groups (75 ± 18, 75 ± 14, p = 0.77, respectively) at 4 weeks postoperatively. VAS scores improved significantly in two studies and NRS at rest and during activity improved significantly (p < 0.001) in a separate study. Overall, 88.1% of the enrolled patients were discharged the same day of surgery, as expected. Out of the 6 studies reporting on readmissions rate, there were two (0.34%) readmissions within 3 months of surgery.

CONCLUSION

In patients with no significant comorbidities, outpatient THA leads to favourable outcomes as well as low readmission rates in the short term.

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.

Unicompartmental knee arthroplasty undertaken using a fast-track protocol

Aims

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BACKGROUND

The Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.

METHODS

This is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.

RESULTS

Controlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.

CONCLUSION

For patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.

Preferential inhibition of adaptive immune system dynamics by glucocorticoids in patients after acute surgical trauma

Glucocorticoids (GC) are a controversial yet commonly used intervention in the clinical management of acute inflammatory conditions, including sepsis or traumatic injury. In the context of major trauma such as surgery, concerns have been raised regarding adverse effects from GC, thereby necessitating a better understanding of how GCs modulate the immune response. Here we report the results of a randomized controlled trial (NCT02542592) in which we employ a high-dimensional mass cytometry approach to characterize innate and adaptive cell signaling dynamics after a major surgery (primary outcome) in patients treated with placebo or methylprednisolone (MP). A robust, unsupervised bootstrap clustering of immune cell subsets coupled with random forest analysis shows profound (AUC = 0.92, p-value = 3.16E-8) MP-induced alterations of immune cell signaling trajectories, particularly in the adaptive compartments. By contrast, key innate signaling responses previously associated with pain and functional recovery after surgery, including STAT3 and CREB phosphorylation, are not affected by MP. These results imply cell-specific and pathway-specific effects of GCs, and also prompt future studies to examine GCs' effects on clinical outcomes likely dependent on functional adaptive immune responses.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postoperative 30-day complications after cemented/hybrid versus cementless total hip arthroplasty in osteoarthritis patients > 70 years

Background and purpose - The use of cementless total hip arthroplasty (THA) in elderly patients is debated because of increased risk of early periprosthetic femoral fractures. However, cemented femoral components carry a risk of bone cement implantation syndrome. Hence, we compared in-hospital complications, complications leading to readmission and mortality ≤ 30 days postoperatively between hybrid/cemented (cemented femoral component) vs. cementless THA in osteoarthritis patients > 70 years.Patients and methods - This is a prospective observational cohort study in 9 centers from January 2010 to August 2017. We used 30-day follow-up from the Danish National Patient Registry, patient records, and data from the Danish Hip Arthroplasty Register. Only THAs performed as a result of osteoarthritis were included.Results - 3,368 (42%) of the THAs were cemented/hybrid and 4,728 (58%) cementless. The in-hospital complication risk was 7.7% after cemented/hybrid vs. 5.3% after cementless THA (< 0.001), statistically not significant when adjusting for comorbidities (p = 0.1). There were similar risks of complications causing readmission (5.7% vs. 6.2%) and mortality ≤ 30 days (0.2% vs. 0.3%). 15 cases (0.4%) of pulmonary embolism (PE) were found after cemented/hybrid vs. 4 (0.1%) after cementless THA (p = 0.001); none occurred within 24 hours postoperatively. 2 of the PEs after cementless THA led to mortality. Cemented/hybrid THA remained significantly associated with risk of PE (RR 3.9, p = 0.02), when adjusting for comorbidities. BMI > 35 was associated with highest risk of PE (RR 5.7, p = 0.003). The risk of periprosthetic femoral fracture was 0.2% after cemented/hybrid vs. 1.5% after cementless THA (p < 0.001) and the risk of dislocations was 1.2% after cemented/hybrid THA vs. 1.8% after cementless THA (p = 0.04).Interpretation - The higher risk of PE after cemented/hybrid THA and higher risk of periprosthetic femoral fractures and dislocations after cementless THA highlights that both medically and surgically complications are related to fixation technique and have to be considered.

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

BACKGROUND

Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices.

OBJECTIVES AND METHODS

We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery).

RESULTS

A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy.

CONCLUSIONS

The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Fast-track hip and knee arthroplasty in older adults-a prospective cohort of 1,427 procedures in patients ≥85 years

INTRODUCTION

fast-track protocols in total hip and knee arthroplasty (THA/TKA) have improved postoperative recovery and reduced postoperative morbidity. Additionally, increasing life expectancy and improved surgical techniques have led to an increasing number of older adult patients undergoing THA/TKA. However, no large detailed studies on fast-track THA/TKA in older adults are available. Consequently, we aimed to describe the length of stay (LOS) and postoperative morbidity in a large cohort of patients ≥85 years within a continuous multicentre fast-track collaboration.

METHODS

we used a prospective observational cohort design with unselected consecutive data between 2010 and 2017 on primary elective THA and TKA patients ≥85 years. Data were obtained from nine centres reporting to the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement database and the Danish National Patient Registry on LOS, readmissions and mortality. Causes of morbidity were determined by review of health records.

RESULTS

we included 1,427 (3.9% of all THA/TKA) procedures with 62.3% THA. Median age was 87 (IQR: 85-88) years with 71% women. LOS decreased from median 4 (3-6) days in 2010 to 2 (2-3) days in 2017. The proportion with LOS > 4 days decreased from 32 to 18%. Readmission and mortality rate remained at about 11.7 and 0.9% after 30 days and 16.0 and 1.5% after 90 days, respectively.

CONCLUSION

this detailed large multicentre fast-track THA/TKA study in patients ≥85 years found major reductions in LOS without increase in readmission or mortality rates. The unchanged readmission rate poses an area for further improvements.

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Importance

The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.

Objective

To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Design, Setting, and Participants

This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.

Exposures

Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.

Main Outcomes and Measures

The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.

Results

During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001).

Conclusions and Relevance

An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

[Anesthesiological concepts in fast-track arthroplasty]

Whereas only a few years ago the only expectation of skilful anesthesia was an undisturbed execution of surgical procedures, today this has changed to a perioperative responsibility in which all physicians involved in the treatment process try to optimize the existing circumstances and risks of the patient before, during and after surgery. Thus, the tasks for the anesthesiologist have been mainly extended to a rapid recovery strategy with as few side effects as possible, such as nausea and vomiting or postoperative cognitive deficits (POCD). The establishment of evident structures and the introduction of suitable perioperative procedures with the goal of maintaining homeostasis, adequate opioid-sparing pain treatment and rapid postoperative convalescence determine the anesthesiological fast-track concept.

Limited Influence of Comorbidities on Length of Stay after Total Hip Arthroplasty: Experience of Enhanced Recovery after Surgery

Objectives

To identify predictors of length of stay (LOS) after total hip arthroplasty (THA) in an enhanced recovery after surgery (ERAS) program and evaluate the safety and cost‐efficiency of the ERAS program with reduced LOS for unselected patients in a Chinese population.

Methods

A total of 311 consecutive, unselected patients undergoing primary THA at a single institution were retrospectively reviewed and divided into two groups: LOS ≤ 3 and LOS > 3 group. All patients were managed with the same ERAS protocol and went back home after discharge. Multivariate logistic regression analysis was used to determine independent risk factors for LOS > 3. Harris Hip Score at 90‐day follow‐up, 90‐day readmission rate, and hospitalization costs were compared between two groups.

Results

Multivariate regression analysis identified female gender (odds ratio [OR] = 2.623), living alone (OR = 4.127), and primary osteoarthritis of hip (OR = 3.565) to be correlated with LOS > 3. Preoperative hemoglobin (HB), postoperative HB, drain use, blood transfusion, diabetes, respiratory disease, osteoporosis, number of comorbidities, and CCI score showed no significant influence on LOS after adjusting for other risk factors in the multivariate model. Harris Hip Score and readmission rate at 90‐day follow‐up showed no significant differences between two groups. Patients in LOS > 3 group had approximately 3948.6 Chinese yuan higher hospital costs.

Conclusion

Female gender, living alone, and primary osteoarthritis of hip were identified as independent risk factors for prolonged LOS. The experience from our institution suggested aggressive management of comorbidities in the ERAS program can minimize the influence of comorbidities on LOS. The safety, efficiency, and costs‐saving benefits of the ERAS program with reduced LOS for unselected patients was confirmed in this study.

Effects of an aging population on hospital costs related to elective hip replacements

OBJECTIVES

Elective hip replacement is a common procedure for elderly people with osteoarthrosis. With more elderly people in the future, the demand for hip replacements will increase and put additional constraints on hospital services. The objective was to explore the future need for hip replacements and related costs and to investigate if anticipated future efficiency gains might alleviate the strain of increased demand.

STUDY DESIGN

Registry-based modelling study.

METHODS

Data were obtained from the Irish Central Statistics Office and the national Hospital Inpatient Enquiry system for 2011-2017. We estimated the future demand for hip replacements each year until 2051 and analysed changes in hip replacement rates and the average length of stay. These assumptions were used in our projections.

RESULTS

Assuming no change in procedure rates, the annual cost of providing elective hip replacements is expected to increase by 1060 (30%) episodes in 2026 which implies a cost increment of €16M (33%) (vs 2017-level). If the historical increase in the procedure rate is assumed, the cost will increase by €33M (67%). If the observed reduction in length of stay can be maintained, costs will reduce by €14M (29.0%). Such a cost saving may alleviate the effect of the demographic changes and observed increases in procedure rates.

CONCLUSIONS

Steady-state assumptions are unrealistic and efficiency gains can alleviate future pressure from population growth. However, this analysis has not addressed the present insufficient capacity of public hospitals to meet population needs, as judged by waiting lists and transfers to private hospitals.

Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study

OBJECTIVE

To determine if same-day discharge total knee arthroplasty (TKA) or total hip arthroplasty (THA) is not associated with increased risk of unplanned readmission and adverse outcomes within 30 days of surgery.

DESIGN

This is a population-based observational study.

SETTING

Patients from 708 participating institutions who underwent primary TKA or primary THA between 2011 and 2017 were divided into three groups by length of stay (LOS 0, 1 and 2-3 days). All patients with LOS>3 days were excluded from the current study. Regression analysis and propensity score matching were performed.

DATA SOURCES

American College of Surgeons-National Surgical Quality Improvement Programme database.

MAIN OUTCOMES AND MEASURES

Primary outcomes included unplanned readmission and cardiac/pulmonary complications within 30 days of surgery.

RESULTS

We identified 226 481 TKA (LOS 0=3118, LOS 1=31 404, and LOS 2-3=1 91 959) and 140 557 THA patients (LOS 0=2652, LOS 1=29 617, and LOS 2-3=1 08 288). There were no differences in 30-day mortality. After adjusting for relevant covariates, LOS 0 (compared with LOS 1) was associated with higher odds of cardiac/pulmonary complications in both TKA (OR 1.95, 95% CI 1.20 to 3.16; 0.67% vs 0.37%) and THA (OR 1.96, 95% CI 1.05 to 3.64; 0.57% vs 0.26%). There were no statistical differences in unplanned readmissions between LOS 0 and LOS 1 groups in TKA (2.41% vs 2.31%) and THA (1.62% vs 2.04%).

CONCLUSIONS

LOS 0 discharge after TKA and THA was associated with higher odds of cardiac/pulmonary complications compared with LOS 1 discharge. While the overall burden of complications is relatively low, until future studies can confirm or challenge our findings, a measured approach is advisable when recommending discharge of patients on the same day of surgery.

Pay less and spend more-the real value in healthcare procurement

Healthcare performances have been for long evaluated according to outcomes and costs. What still needs to be defined is which outcomes are the most relevant to the patient, and which costs any supplier is capable to reduce, or increase, to the funder. If technical efficiencies during healthcare production and delivery may continue to evolve, the opportunities for further savings are likely to decrease. Major improvement could be achieved from better definition of outcomes that really matters to patients and stakeholders, that is measuring the real value. Many purchasers are shifting from a traditional approach based on single-unit cost-saving to a more holistic approach, encompassing long-lasting performance evaluation, including the highest possible number of stakeholders and wider sets of indicators. Value-based procurement (VBP) has been defined as achieving "outcomes that matter to people at the lowest possible cost". Although this approach may appear complicated in practice, it was already proven successful in different countries, medical and surgical applications, and has also been endorsed by some important international institutions. The scope of this review is to introduce VBP from a theoretical and an empirical level, referring to relevant practices and challenges which emerged in the current institutional, clinical and academic debate. VBP seems to be a promising solution to improve healthcare efficiency and fairness, provided a clear conception of what is value and a permanent collaboration between clinicians and scientists. When different dimensions of value (i.e., personal, technical, allocative and societal) are supported by well-designed study to identify the respective outcomes, it becomes easier to find better solutions in support of healthcare quality and sustainability.