Is there a need for routine follow-up after primary total hip arthroplasty?

ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty

This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Utility of Routine Postoperative Radiographs in the Asymptomatic Total Hip Arthroplasty Patient

BACKGROUND

Total hip arthroplasty (THA) patients often receive routine radiographs in the year following their index surgery. This study sought to investigate the clinical and economic value of obtaining routine postoperative hip radiographs for asymptomatic patients following primary elective THA.

METHODS

A retrospective cohort study of consecutive patients who underwent primary elective THA from 2016 to 2019 was conducted. Patients undergoing nonelective or revision THA, radiographic follow-up <10 months, and patients aged <18 years were excluded. All radiographs were reviewed for abnormalities in the first postoperative year by an arthroplasty fellowship-trained orthopaedic surgeon, blinded to the symptoms of the patient.

RESULTS

Of the 327 patients (351 hips) included, 57.2% were women and 68.2% were White, with an average age of 65 years (range, 22-97 years) and average body mass index of 29.1 kg/m² (range, 16.2-49.8 kg/m²). Only four (0.4%) radiographic series revealed abnormalities with the potential to alter postoperative management. One patient experienced a change in management directly related to their abnormal finding (closed reduction for dislocation at 10.2 months postoperatively). The remaining three abnormal radiographic findings included femoral stem subsidence, progressive radiolucencies around an acetabular component, and cement mantle fracture. The average cost for each radiographic series was $155.27, resulting in total direct charges of $167,691.60.

CONCLUSION

Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. Consideration should be given to limit postoperative radiographs following standard elective THA, while reserving postoperative radiographic evaluation for patients who are symptomatic.

LEVEL OF EVIDENCE

Level III.

Techniques and Strategies to Optimize Efficiencies in the Office and Operating Room: Getting Through the Patient Backlog and Preserving Hospital Resources

The effects of the coronavirus disease 2019 pandemic are pervasive and have decreased the volume of hip and knee arthroplasty procedures since the mandated cessation of elective surgical procedures at the height of the pandemic in early 2020. Therefore, a backlog of patients in need of these elective procedures is a probable consequence and increased productivity and efficiency in patient care delivery is essential now and into the future. This article outlines multiple strategies and techniques to develop and optimize efficiency in the hip and knee arthroplasty practice. Techniques for increasing surgical efficiency are detailed, along with perioperative strategies in the hospital, ambulatory surgery center, and office settings are outlined and discussed.

Pilot study: Is a long-term follow-up service beneficial for patients undergoing revision hip replacement surgery?

Purpose

Total hip arthroplasty (THA) is highly successful but some patients will require later revision surgery. This pilot study evaluates the effects of long‐term follow‐up for patients undergoing revision hip replacement.

Methods

Consecutive patients undergoing aseptic revision of THA were recruited from a large orthopaedic unit to a single centre, observational study. Primary outcomes were changes in patient‐reported scores from pre‐revision to 12 months post‐surgery. Secondary outcomes were costs during hospital stay up to 6 months post‐revision. Participants were retrospectively allocated to two groups—those with regular orthopaedic review prior to revision (Planned revision) or those without (Unplanned revision).

Results

52 patients were recruited, 7 were unrevised, one incomplete baseline questionnaires. There were 25 planned and 19 unplanned revisions with no significant differences between groups at baseline. At 12 months, 34 complete data sets were available for analysis, 17 in each group. Change scores were analysed with Mann–Whitney U test; none reached statistical significance. There was a significant difference for length of stay: Planned group 5 days (2–22), Unplanned 11 days (3–86) (Mann–Whitney U test, p = 0.023). No significant differences found for theatre time or component costs. Resource costs post‐revision surgery are presented.

Conclusion

This pilot study indicates that some change in methods would be required for future work. The results show that there may be some financial benefit from providing long‐term follow‐up of THA but a larger study is needed to explore these findings and to discuss the impact on recommended guidelines.

Routine follow-up is unnecessary after intramedullary fixation of trochanteric femoral fractures-Analysis of 995 cases

BACKGROUND AND PURPOSE

Approximately 2000 trochanteric fractures are operated in Finland annually. These fractures make a major burden to health care system and affected individuals. The role of routine follow-up has been questioned in multiple fracture types.

PATIENTS AND METHODS

We analyzed routine follow-up visits after intramedullary fixation of trochanteric fractures (n = 995). Patients were followed up from patient registries until 2 years or death. Planned and unplanned follow-up visits were analyzed.

RESULTS

Altogether 9 patients (0.9%) had a change in treatment at planned outpatient visit. 6 of these were due to mechanical complication, 1 due to refracture and 2 due to delayed unions. 64 (6.4%) patients had a change in treatment plan because of an unplanned visit: 28 infections, 6 pressure sores, 15 mechanic complications and 14 refractures and 1 AVN, respectively.

INTERPRETATION

Routine follow-up visits are a burden both to the patients and health care system, with less than 1% leading to changes in treatment. Our suggestion is to give good instructions to patients and rehabilitation facilities instead of routine follow-up.

Systematic review of the clinical effectiveness for long-term follow-up of total hip arthroplasty

Objectives: Total hip arthroplasty (THA) is highly successful but national registries indicate that average age has lowered and that younger patients are at higher risk of revision. Long-term follow-up of THA was historically recommended to identify aseptically failing THA, minimising the risks associated with extensive changes, but follow-up services are now in decline. A systematic review was conducted to search for evidence of the clinical or cost-effectiveness of hip arthroplasty surveillance. Methods: The study was registered with PROSPERO International Prospective Register of Systematic Reviews and conducted according to PRISMA guidelines; databases included MEDLINE and Embase, and all studies were quality assessed. Original studies (2005 to 2017) reporting follow-up of adults with THA in situ >5 years were included. Researchers extracted quantitative and qualitative data from each study. Results: For eligibility, 4,137 studies were screened: 114 studies were included in the final analysis, representing 22 countries worldwide. Data extracted included study endpoint, patient detail, loss to follow-up, revisions, scores and radiographic analysis. Six themes were derived from inductive content analysis of text: support for long-term follow-up, subgroups requiring follow-up, effect of materials/techniques on THA survival, effect of design, indicators for revision, review process. Main findings-follow-up was specifically recommended to monitor change (eg asymptomatic loosening), when outcomes of joint construct are unknown, and for specific patient subgroups. Outcome scores alone are not enough, and radiographic review should be included. Conclusion: There were no studies directly evaluating the clinical effectiveness of the long-term follow-up of THA but expert opinions from a range of international authors advocated its use for defined subgroups to provide patient-centred care. In the absence of higher level evidence, these opinions, in conjunction with emerging outputs from the national joint registries, should be used to inform services for long-term follow-up of THA.

Optimizing postoperative follow-up in pediatric surgery (OFIPS)

BACKGROUND/PURPOSE

The purpose of the study was to determine variables associated with attending postoperative clinic follow-up (POFU) in pediatric surgical patients, predictors of clinical value, and visit cost estimates.

METHODS

POFU patterns of children undergoing eight common pediatric surgical procedures over one year at a tertiary pediatric hospital were examined retrospectively. Variables associated with attending POFU and associated with predetermined measures of clinical value and cost were determined. Driving distance to hospital was chosen as a proxy measure of cost to the family.

RESULTS

Six-hundred-thirty-three patients were included, and 58% attended POFU. Variables independently associated with attending follow-up included: procedure type (orchidopexy, complicated appendicitis), living close to the hospital, having a defined follow-up order, individual surgeon attending. Clinical value was identified in 16.4% of patient visits and associated with orchidopexies, having required an earlier urgent postoperative visit and longer cases considered "complex". Significant costs to the health care system (~$125,000) and families (~$15,000) could be estimated from follow-up cases that had no clinical issues identified nor required an intervention.

CONCLUSION

POFU of common pediatric surgical procedures may have limited clinical value while coming at significant costs to families and the health care system. Further study is needed to define optimal needs and means of follow-up of these common pediatric surgical procedures.

LEVEL OF EVIDENCE

Level III.

Guidelines for the follow-up of total hip arthroplasty

Aims

The aim of this retrospective audit was to determine the route of referral or presentation of patients requiring revision following primary total hip arthroplasty (THA).

Patients and Methods

A total of 4802 patients were implanted with an Orthopaedic Data Evaluation Panel (ODEP) 10A* cementless implant (Corail/Pinnacle) between 2005 and 2015; 80 patients with a mean age of 67.8 years (sd 10.8) underwent a subsequent revision. The primary outcome measure was route of referral for revision.

Results

Of the 80 revisions, 31 (38.8%) took place within the first year and 69 (86.3%) took place within six years. Only two of the 80 patients were picked up at a routine review clinic, one for infection and the other for liner dissociation. A total of 36 revised patients (45.0%) were reviewed following self-referral. Of the remaining 44 revised patients (55.0%), 15 (18.8%) were General Practitioner referrals, 13 (16.3%) were other hospital referrals, six (7.5%) were inpatients, six (7.5%) were Emergency Department referrals, and two (2.5%) were readmitted from their homes. No revisions were carried out on asymptomatic patients.

Conclusion

Our experience suggests that if there is a robust system in place for self-referral, patients with an ODEP 10A* hip implant can, if asymptomatic, be safely discharged at the time of their first postoperative review. Cite this article: Bone Joint J 2019;101-B:536–539.

Two and a half years on: data and experiences establishing a 'Virtual Clinic' for joint replacement follow up

BACKGROUND

We use a 'Virtual Clinic' for follow up of hip and knee replacement patients. The aim of this study was to investigate patient compliance, pain and function, revision rates and surgeon experience using this system.

METHODS

All hip and knee replacements conducted from 2000 onwards were suitable for 'Virtual Clinic' review. Between July 2014 and December 2016, all patients due for follow up (at 1, 5 and 7 years post-operatively, or biennially thereafter) were mailed an Oxford Hip or Knee Score and a request for a radiograph. A surgeon reviewed the questionnaire and radiograph and decided whether face-to-face review was necessary. We calculated compliance as the percentage of eligible patients who completed the 'Virtual Clinic'. We used retrospective review of medical records for all clinic participants to analyse Oxford scores, disposition following appointment, and revision rates. We reviewed all clinic participants in December 2017 to identify any further revisions. Surgeon feedback was assessed by emailed survey.

RESULTS

A total of 2076 patients were due for follow up. 1405 patients were contactable, and 710 completed the process. We calculated a 36% compliance rate. Surgeons decided 162 (23%) patients with a mean Oxford score of 24.2 required face-to-face assessment. This identified 13 patients needing revision. One other patient was revised for loosening which developed between 'Virtual Clinic' appointments. Surgeon feedback indicated the inclusion of a 'comment' section on the questionnaire as particularly useful.

DISCUSSION

We describe our adoption of a 'Virtual Clinic' for joint replacement follow up. We recommend this system as a practical method of following up patients.

Identifying complications requiring re-operation following primary hip or knee arthroplasty: a consecutive series of 98 patients

BACKGROUND

The number of hip and knee arthroplasties completed is expected to double over the next decade. In public hospitals, regular post-arthroplasty orthopaedic review has commonly occurred for the duration of a patient's life, which requires substantial outpatient resources. However, there is limited evidence regarding the utility of these reviews for identifying complications. The current study investigated when and where complications requiring re-operation were identified following primary hip or knee arthroplasty.

METHODS

The medical records of all patients requiring re-operation for complications following primary hip arthroplasty (n = 48, 2004 to 2015) or knee primary arthroplasty (n = 50, 1998 to 2015) at a large regional health service were evaluated. Data were extracted by one of four investigators using a standardised electronic data extraction tool. Variables of interest included the health setting where the complication was initially identified, how long following the original operation the complication was identified and whether the complication was symptomatic.

RESULTS

Routine post-arthroplasty orthopaedic appointments identified 15 (15.3%) complications requiring re-operation; all were identified in the first-year post-surgery. For each complication identified in the first-year post-surgery, approximately 1000 orthopaedic outpatient appointments were required. After the first year, all complications were identified in Emergency Departments (n = 30, 30.6%), General Practice (n = 24, 24.5%) or non-routine orthopaedic outpatient appointments (n = 19, 19.4%). All patients with complications reported symptoms.

CONCLUSIONS

Routine post-arthroplasty review appointments were an inefficient mechanism for identifying complications requiring re-operation more than one year following surgery. Public health services should consider assessing and redesigning post-arthroplasty review services to reduce the burden on patients and the demand for outpatient appointments.

Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring?

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using 'virtual' clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6-10.

Evaluation of a routine follow-up visit after an internal fixation of proximal femoral fracture

BACKGROUND AND PURPOSE

Post-operative follow-up after internal fixation of fractures is a common practice. The goal of this study was to evaluate the necessity of a routine follow-up visit after internal fixation of a proximal femoral fracture. Our hypothesis is that these follow-up visits do not result in a change in the treatment plan, but add an extra cost to the health care system and lead to the purposeless utilisation of limited resources.

PATIENTS AND METHODS

A retrospective study of 428 consecutive patients (431 fractures) with a scheduled outpatient clinic visit after internal fixation of proximal femoral fractures in a single hospital during years 2012-2013. We noted any changes in the patients' treatment plans based on the first follow-up visits, including scheduled visits up to ten weeks after internal fixation.

RESULTS

None of the patients showed signs of infection, implant failure or loss of reduction requiring re-operation at the scheduled follow-up visit. In only one (0.23%) visit a change in treatment plan was made as a result of the scheduled follow-up visit (decision to remove the distal screws from the long intramedullary nail to obtain dynamic compression). Scheduled visits did not occur for the following reasons, death (11.8%), visit to emergency department prior scheduled visit (3.2%), and not known (3.9%).

CONCLUSIONS

The first scheduled visit within ten weeks after internal fixation of a proximal femoral fracture leads to no changes in treatment. We recommend considering the need of these follow-up visits.

Cost-Effective Mobile-Based Healthcare System for Managing Total Joint Arthroplasty Follow-Up

Objectives

Long-term follow-up care after total joint arthroplasty is essential to evaluate hip and knee arthroplasty outcomes, to provide information to physicians and improve arthroplasty performance, and to improve patients' health condition. In this paper, we aim to improve the communication between arthroplasty patients and physicians and to reduce the cost of follow-up controls based on mobile application technologies and cloud computing.

Methods

We propose a mobile-based healthcare system that provides cost-effective follow-up controls for primary arthroplasty patients through questions about symptoms in the replaced joint, questionnaires (WOMAC and SF-36v2) and the radiological examination of knee or hip joint. We also perform a cost analysis for a set of 423 patients that were treated in the University Clinic for Orthopedics in Essen-Werden.

Results

The estimation of healthcare costs shows significant cost savings (a reduction of 63.67% for readmission rate 5%) in both the University Clinic for Orthopedics in Essen-Werden and the state of North Rhine-Westphalia when the mobile-based healthcare system is applied.

Conclusions

We propose a mHealth system to reduce the cost of follow-up assessments of arthroplasty patients through evaluation of diagnosis, self-monitoring, and regular review of their health status.

Empirical support for radiographic review: a follow-up study of total hip arthroplasty

Routine post surgery surveillance of total hip arthroplasty (THA) is widely recommended to identify asymptomatic failure but inclusion of an x-ray adds to service costs. Evidence is needed to support orthopaedic opinion in order to identify what should be included in surveillance. An investigation was conducted to establish whether an x-ray is needed in addition to patient reported outcome measures. One hundred and fifty-four THA had been assessed at 3 years and were reviewed again at 6 to 9 years (mid-term) when radiographic signs of deterioration commonly appear. Data were explored for associations between radiographic changes and changes in the participants' Oxford Hip Score, age, EuroQol 5-D score or comorbidities. Hierarchical multiple regression analysis showed that the number of radiographic changes could not be predicted by any of the other variables. This supports the inclusion of an x-ray in THA surveillance and suggests that the state of the THA cannot be determined by the use of patient reported outcome measures alone. This has implications for future arthroplasty surveillance.

Reliability of the radiological assessments of radiolucency and loosening in total hip arthroplasty using PACS

We evaluated the reliability of three commonly used radiological assessments of total hip arthroplasty (THA) using the electronic picture archiving and communications system (PACS). Thirty-three patients were selected at random at a mean of 7.2 years after THA. The Barrack, Gruen and Hodgkinson evaluations of cementing quality, loosening/radiolucency were graded. Three observers assessed each radiograph (one consultant orthopaedic surgeon, one senior orthopaedic registrar and one senior house officer). Four weeks after the initial assessment, each radiograph was reviewed a second time. The findings indicated that the intra- and inter-observer reliability of the Barrack, Gruen and Hodgkinson methods were questionable. Inter-observer reliability using the Gruen system was poor, using the Barrack system it was moderate to good, and fair to good using the Hodgkinson assessment. Intra-observer reliability was moderate to good for Barrack assessment, poor to good using Gruen zone assessments, but good to very good for the Hodgkinson assessment. The use of Barrack, Gruen and Hodgkinson assessments to evaluate femoral and acetabular loosening should be questioned since these exhibit limited inter- and intra-observer reliability on PACS radiographs, but of the three, the Hodgkinson system is the most reliable.

Patient satisfaction with postoperative follow-up by a hand therapist

PURPOSE

There has been a move to reduce and, indeed, stop postoperative appointments for uncomplicated surgical procedures within the National Health Service. The purpose of this study was to measure patient satisfaction with postoperative follow-up conducted by a hand therapist, with no routine postoperative follow-up by the surgeon.

METHODS

A total of 124 patients were recruited over two years. Fifty patients post-simple trapeziectomy and 74 patients post-single-digit Dupuytren's fasciectomy were prospectively surveyed for their opinion on their postoperative care and whether or not they would have liked to be reviewed by the surgeon in a routine postoperative follow-up appointment. All patients included in this study had their operations performed by one surgeon in one hospital. All patients were reviewed by a hand therapist within two weeks of surgery.

RESULTS

A total of 116 patients completed the study, of whom 106 patients (91%) were satisfied with their postoperative management and 99 patients (85%) did not want to be reviewed by the surgeon in a postoperative outpatient follow-up appointment.

DISCUSSION

This study reflects the successful application of postoperative follow-up by a hand therapist.