Incidence and Associated Risk Factors for Falls in Older Adults After Elective Total Knee Replacement Surgery: A Prospective Cohort Study

Risk factors of post discharge falls in patients undergoing total knee arthroplasty: An integrative review

BACKGROUND

Total knee arthroplasty (TKA) is a widely performed surgical procedure aimed at alleviating pain and restoring functionality in individuals suffering from knee osteoarthritis. Despite substantial benefits of TKA, patients are exposed to potential risks, including the occurrence of falls during their recovery period following discharge from the hospital.

OBJECTIVE

This integrative review endeavors to comprehensively investigate the existing body of literature to identify and assess the diverse factors that contribute to occurrence of post-discharge falls among TKA patients. Through the synthesis of available research, this study seeks to offer valuable insights that can guide clinical practices and interventions designed to mitigate the incidence of post-TKA falls, ultimately enhancing patient outcomes and quality of healthcare.

METHODS

An integrative review was conducted and databases were searched including Pubmed, PEDro, Cochrane, and SPORTDiscus from 2000 to 2024. A thorough search was performed to retrieve articles missed through databases as well as unpublished grey literature. Methodological quality assessment was performed using Newcastle-Ottawa Scale for Case Control and Cohort studies and AXIS tool for cross-sectional study.

RESULTS

Eleven articles finally met the inclusion criteria and were included in the review based on eligibility. There were 8 cohort studies (7 prospective cohorts, 1 retrospective cohort), 2 case control studies, and 1 cross-sectional study. The prospective cohort studies included in the review collected data in real-time as events occurred, making them particularly relevant for studying post-TKA falls.

CONCLUSION

Patients who underwent TKA are at risk of post-discharge falls. Several key risk factors have been identified, including advancing age, female gender, reduced proprioception, psychiatric disorders, living alone, and knee pain in the operated knee. It is important to recognize that the significance of these risk factors can vary depending on individual circumstances and contexts.

The impact of mental state altering medications on preventable falls after total hip or total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Joint replacement surgery of the lower extremities are common procedures in elderly persons who are at increased risk of postoperative falls. The use of mental state altering medications, such as opioids, antidepressants or benzodiazepines, can further contribute to impaired balance and risk of falls. The objective of the current systematic review was to evaluate the risk of the use of mental state altering medications on postoperative falls in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

A comprehensive search of Medline, Embase and Cochrane Controlled Trials Register was conducted from 1 October 1975 to 1 September 2021. The search was repeated in may 2023 and conducted from 1 October 1975 to 1 June 2023. Clinical trials that evaluated the risk of medication on postoperative THA and TKA falls were eligible for inclusion. Articles were evaluated independently by two researchers for risk of bias using the Newcastle-Ottawa Scale. A meta-analysis was performed to determine the potential effect of postoperative use of mental state altering medications on the risk of falls. Lastly, a qualitative synthesis was conducted for preoperative mental state altering medications use.

RESULTS

Seven cohort studies were included, of which five studies focussed on the postoperative use of mental state altering medications and two investigated the preoperative use. Meta-analysis was performed for the postoperative mental state altering medications use. The postoperative use of mental state altering medications was associated with fall incidents (OR: 1.81; 95% CI: 1.04; 3.17) (p < 0.01) after THA and TKA. The preoperative use of opioids > 6 months was associated with a higher risk of fall incidents, whereas a preoperative opioid prescription up to 3 months before a major arthroplasty had a similar risk as opioid-naïve patients.

CONCLUSIONS

The postoperative use of mental state altering medications increases the risk of postoperative falls after THA and TKA. Prior to surgery, orthopaedic surgeons and anaesthesiologists should be aware of the associated risks in order to prevent postoperative falls and associated injuries.

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

BACKGROUND

Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.

METHODS

A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.

RESULTS

Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).

CONCLUSIONS

There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.