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

Safety and Effectiveness of Robotic-Arm Assisted Total Knee Arthroplasty

OBJECTIVE

We investigated the advantages of robotic arm-assisted total knee arthroplasty (raTKA) over conventional manual TKA (cmTKA) by comprehensively comparing patients who received raTKA and cmTKA in terms of postoperative pain, function, imaging assessment, and trauma to the body. This study investigated the efficacy and safety of raTKA in patients using the YUANHUA-TKA system.

METHODS

In a prospective, randomized single-blind trial, 60 patients undergoing primary unilateral TKA from October 2020 to December 2020 were randomly assigned to either raTKA or cmTKA. Clinical evaluation, including the time of osteotomy and prosthesis model testing, the total operation time, the visual analogue scale at rest, VAS in motion, opioid consumption, white blood cell count, neutrophil ratio, erythrocyte sedimentation rate, C-reactive protein (CRP), passive and active range of motion (pROM, aROM), Western Ontario and McMaster Universities Arthritis Index (WOMAC [stiffness, pain, and function]) score, gait analysis, keen society score (KSS), adverse events, and blood loss were collected by the project nurse, as well as the imaging evaluation, including the lateral tibia component angle (LTC), frontal femoral component angle, frontal tibia component angle (FTC), lateral femoral component angl, and hip-knee-ankle angle (HKA). The student t-test (or the Wilcoxon signed-rank test) and the χ2-test (or the Fisher exact test) were used to determine differences in categorical variables.

RESULTS

No significant difference was found between the two groups in pain throughout the whole follow-up period. On the third day postoperatively, the erythrocyte sedimentation rate in the cmTKA group was significantly higher (p = 0.02), as well as the CRP (p = 0.04). No significant difference was found in the WOMAC stiffnes score or pROM. However, the aROM and the flexion range when walking (FRW) were significantly better in the raTKA group throughout the trial (p < 0.05). The KSS at the 1-month follow-up and the WOMAC function score at the 1-year follow-up were both significantly better in the raTKA group (p < 0.05). The HKA and the LTC in the raTKA group closer to the ideal angle, and the difference between the groups was significant (p < 0.05). The total operation time of the raTKA group was significantly longer (p = 0.001). The intraoperative blood loss had no significant difference in the two groups.

CONCLUSION

Compared with cmTKA, raTKA with the YUANHUA robot not only avoids extra pain and trauma in patients but promises better functional recovery and improves the accuracy of the prosthesis position and axial alignment reconstruction.

Impact of fast-track rehabilitation nursing on pressure ulcers and postoperative complications in patients with inter-trochanteric fractures: A meta-analysis

We sought to investigate the effects of fast-track rehabilitation nursing on pressure ulcers, length of hospital stay and postoperative complications in patients with inter-trochanteric fractures (ITF). The PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure and WanFang databases were searched for randomised controlled trials (RCTs) published from inception to September 2023 on the application of fast-track rehabilitative nursing to ITF. Two investigators independently screened the literature and performed data extraction and quality assessments using the Cochrane Risk of Bias Assessment Tool. The meta-analysis was performed using RevMan 5.4. Overall, 22 RCTs involving 1904 patients were included. Meta-analysis revealed that after fast-track rehabilitation nursing intervention in patients with ITF, the occurrence of pressure ulcers (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.18-0.47; p < 0.001) and postoperative complications (OR: 0.19; 95% CI: 0.14-0.26; p < 0.001) were significantly reduced and hospital stay was significantly shorter (standardised mean difference: -3.10; 95% CI: -3.82 to -2.38; p < 0.001). Nursing care for patients with ITF based on the concept of fast-track rehabilitation is conducive to reducing the occurrence of pressure ulcers, lowering the occurrence of complications, shortening the length of hospitalisation and promoting postoperative rehabilitation.

Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China

PURPOSE

There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery.

METHODS

This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group.

RESULTS

Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group.

CONCLUSIONS

Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Better early outcome with enhanced recovery total hip arthroplasty (ERAS-THA) versus conventional setup in randomized clinical trial (RCT)

INTRODUCTION

Numbers of total hip arthroplasty (THA) are steadily rising and patients expect faster mobility without pain postoperatively. The aim of enhanced recovery after Surgery (ERAS) programs in a multidisciplinary setup was to keep pace with the needs of quality and quantity of surgical THA-interventions and patients' expectations.

METHODS

194 patients undergoing THA procedures were investigated after single-blinded randomization to ERAS (98) or conventional setup group (96). Primary outcome variable was mobilization measured with the Timed Up and Go Test (TUG) in seconds. Secondary outcome variables were floor count and walking distance in meters as well as rest, mobilization and night pain on a numerous rating scale (NRS). All variables were recorded preoperatively and daily until the sixth postoperative day. To assess and compare clinical outcome and patient satisfaction, the PPP33-Score and PROMs were used.

RESULTS

No complications such as thromboembolic complications, fractures or revisions were recorded within the first week postoperatively in either study group. Compared to the conventional group, the ERAS group showed significantly better TUG (p < 0.050) and walking distance results after surgery up to the sixth, and floor count up to the third postoperative day. On the first and second postoperative day, ERAS patients showed superior results (p < 0.001) in all independent activity subitems. Regarding the evaluation of pain (NRS), PPP33 and PROMS, no significant difference was shown (p > 0.050).

CONCLUSION

This prospective single-blinded randomized controlled clinical trial was able to demonstrate excellent outcome with comparable pain after ERAS THA versus a conventional setup. Therefore, ERAS could be used in daily clinical practice.

Machine Learning Models Based on a National-Scale Cohort Identify Patients at High Risk for Prolonged Lengths of Stay Following Primary Total Hip Arthroplasty

BACKGROUND

Existing machine learning models that predicted prolonged lengths of stay (LOS) following primary total hip arthroplasty (THA) were limited by the small training volume and exclusion of important patient factors. This study aimed to develop machine learning models using a national-scale data set and examine their performance in predicting prolonged LOS following THA.

METHODS

A total of 246,265 THAs were analyzed from a large database. Prolonged LOS was defined as exceeding the 75th percentile of all LOSs in the cohort. Candidate predictors of prolonged LOS were selected by recursive feature elimination and used to construct four machine learning models-artificial neural network, random forest, histogram-based gradient boosting, and k-nearest neighbor. The model performance was assessed by discrimination, calibration, and utility.

RESULTS

All models exhibited excellent performance in discrimination (area under the receiver operating characteristic curve [AUC] = 0.72 to 0.74) and calibration (slope: 0.83 to 1.18, intercept: -0.01 to 0.11, Brier score: 0.185 to 0.192) during both training and testing sessions. The artificial neural network was the best performer with an AUC of 0.73, calibration slope of 0.99, calibration intercept of -0.01, and Brier score of 0.185. All models showed great utility by producing higher net benefits than the default treatment strategies in the decision curve analyses. Age, laboratory tests, and surgical variables were the strongest predictors of prolonged LOS.

CONCLUSION

The excellent prediction performance of machine learning models demonstrated their capacity to identify patients prone to prolonged LOS. Many factors contributing to prolonged LOS can be optimized to minimize hospital stay for high-risk patients.

Significant Analgesic Benefits of Perioperative Duloxetine in Patients Who Have Depressive Symptoms Undergoing Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Major symptoms of depression are commonly observed in patients requiring total hip arthroplasty (THA), and this is associated with increased pain scores and opioid consumption. We aimed to investigate the analgesic effect of duloxetine in these high-risk patients.

METHODS

Among 263 patients scheduled for primary unilateral THA, 67 patients who scored at least 8 on the 17-item Hamilton Depression Scale (HAMD) were enrolled in this study. Patients were randomized to the duloxetine group (60 mg daily, from the day of surgery to postoperative day 6) or the placebo group. The postoperative visual analog scale (VAS) score during walking, the VAS score during hip flexion, and resting VAS score was measured. Postoperative morphine consumption, hip range of motion (ROM), Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, postoperative length of stay (LOS), and adverse events were recorded.

RESULTS

The duloxetine group had significantly lower VAS scores during walking and hip flexion from postoperative day 3 to week 3 than the placebo group. With regard to the resting VAS score, duloxetine showed a better analgesic effect from postoperative day 3 to week 2 than placebo. Patients in the duloxetine group had less consumption of morphine. The duloxetine group exhibited better hip function scores, including ROM, HHS, and WOMAC function scores than the placebo group. No significant difference was observed in LOS or adverse events between groups.

CONCLUSION

Perioperative short-term duloxetine provides advantages in decreasing pain, reducing morphine consumption, and increasing hip function in THA patients who have depressive symptoms.

Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture

BACKGROUND

Because of their poor physical state, elderly hip fracture patients commonly require prolonged hospitalization, resulting in a drop in bed circulation rate and an increased financial burden. There are currently few predictive models for delayed hospital discharge for hip fractures. This research aimed to develop the optimal model for delayed hospital discharge for hip fractures in order to support clinical decision-making.

METHODS

This case-control research consisted of 1259 patients who were continuously hospitalized in the orthopedic unit of an acute hospital in Tianjin due to a fragility hip fracture between January and December 2021. Delayed discharge was defined as a hospital stay of more than 11 days. The prediction model was constructed through the use of a Cox proportional hazards regression model. Furthermore, the constructed prediction model was transformed into a nomogram. The model's performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). the STROBE checklist was used as the reporting guideline.

RESULTS

The risk prediction model developed contained the Charlson Comorbidity Index (CCI), preoperative waiting time, anemia, hypoalbuminemia, and lower limbs arteriosclerosis. The AUC for the risk of delayed discharge was in the training set was 0.820 (95% CI,0.79 ~ 0.85) and 0.817 in the testing sets. The calibration revealed that the forecasted cumulative risk and observed probability of delayed discharge were quite similar. Using the risk prediction model, a higher net benefit was observed than when considered all patients were at high risk, demonstrating good clinical usefulness.

CONCLUSION

Our prediction models could support policymakers in developing strategies for the optimal management of hip fracture patients, with a particular emphasis on individuals at high risk of prolonged LOS.

Prophylactic doxazosin reduces urinary retention and promotes recovery after total joint arthroplasty: A randomized controlled trial

Background: Postoperative urinary retention (POUR) is a common and disruptive complication following total joint arthroplasty (TJA). The aim of this study is to investigate whether doxazosin can decrease the incidence of POUR and promote recovery under the setting of modern enhanced recovery after TJA. Methods: In this randomized placebo-controlled trial, patients over 35 years of age undergoing primary unilateral TJA were recruited. Patients received doxazosin (4 mg once) or placebo 2 h before surgery. The primary outcome of interest was the development of POUR, which was diagnosed when patients with a urine volume over 400 ml or overflow incontinence. Postoperative recovery was assessed in terms of hospital length of stay after surgery, daily ambulation distance, visual analogue scale (VAS) pain score and opioid consumption. Results: A total of 170 male patients were equally randomized into Doxazosin group (mean age 54.2 ± 13.7 years, range 36-88 years) and Placebo group (mean age 54.6 ± 13.9 years, range 38-81 years). The POUR rate was significant lower in Doxazosin group (17.6%) than in Placebo group (36.5%) (p = .006). The mean LOS in the Doxazosin group was 3.1 ± 1.1 days compared to 3.6 ± 1.7 days in the Placebo group (p = .030). Doxazosin group had a longer daily mobilization distance than Placebo group on postoperative day 1 (26.8 ± 11.1 vs. 22.8 ± 9.7; p = .015). Postoperative pain assessed by VAS score and opioid usage was comparable between two groups. Conclusion: Our results support the routine use of prophylactic doxazosin in male patients to decrease POUR rate and promote postoperative recovery under the setting of modern enhanced recovery after TJA.

Patient characteristics and procedural variables are associated with length of stay and hospital cost among unilateral primary total hip arthroplasty patients: a single-center retrospective cohort study

BACKGROUND

Total hip arthroplasty (THA) is a successful treatment for many hip diseases. Length of stay (LOS) and hospital cost are crucial parameters to quantify the medical efficacy and quality of unilateral primary THA patients. Clinical variables associated with LOS and hospital costs haven't been investigated thoroughly.

METHODS

The present study retrospectively explored the contributors of LOS and hospital costs among a total of 452 unilateral primary THA patients from January 2019 to January 2020. All patients received conventional in-house rehabilitation services within our institute prior to discharge. Outcome parameters included LOS and hospital cost while clinical variables included patient characteristics and procedural variables. Multivariable linear regression analysis was performed to assess the association between outcome parameters and clinical variables by controlling confounding factors. Moreover, we analyzed patients in two groups according to their diagnosis with femur neck fracture (FNF) (confine THA) or non-FNF (elective THA) separately.

RESULTS

Among all 452 eligible participants (266 females and 186 males; age 57.05 ± 15.99 year-old), 145 (32.08%) patients diagnosed with FNF and 307 (67.92%) diagnosed with non-FNF were analyzed separately. Multivariable linear regression analysis revealed that clinical variables including surgery duration, transfusion, and comorbidity (stroke) among the elective THA patients while the approach and comorbidities (stoke, diabetes mellitus, coronary heart disease) among the confine THA patients were associated with a prolonged LOS (P < 0.05). Variables including the American Society of Anesthesiologists classification (ASA), duration, blood loss, and transfusion among the elective THA while the approach, duration, blood loss, transfusion, catheter, and comorbidities (stoke and coronary heart disease) among the confine THA were associated with higher hospital cost (P < 0.05). The results revealed that variables were associated with LOS and hospital cost at different degrees among both elective and confine THA.

CONCLUSIONS

Specific clinical variables of the patient characteristics and procedural variables are associated the LOS and hospital cost, which may be different between the elective and confine THA patients. The findings may indicate that evaluation and identification of detailed perioperative factors are beneficial in managing perioperative preparation, adjusting patients' anticipation, decreasing LOS, and reducing hospital cost.

The Role of a Seven-Day Physiotherapy Service in Reducing Length of Stay and Improving Cost-Effectiveness in Arthroplasty Surgery

Background Length of hospital stay post hip and knee arthroplasty is influenced by several factors, including gender, home circumstances and underlying diagnosis. Due to increasing demand for hip and knee arthroplasty, elective units, operating within already stressed healthcare systems, must identify methods of increasing efficiency and capacity. We sought to establish whether the lack of a seven-day inpatient physiotherapy service resulted in an increased hospital length of stay post primary hip and knee arthroplasty. Methods One hundred consecutive joint replacements (50 total hip replacements and 50 total knee replacements (TKRs)), performed in our institution from January to February 2020, were assessed. The length of stay for the cohort was analysed, and delays to discharge were identified. T-test was used to analyse the difference in length of stay based on the day of the week the surgery was performed. Results The mean length of stay for all primary hip and knee arthroplasties was 3.42 (standard deviation (SD): 1.62) days. Hip and knee arthroplasties performed on a Thursday or Friday had a significantly higher average length of stay than those performed on Monday, Tuesday or Wednesday (3.89 versus 3.02, p=0.006). We calculated that operating a six-day versus seven-day physiotherapy service in our unit cost 318 bed days per year equating to €986,535. Conclusion Length of stay post total hip and knee arthroplasty in our unit is significantly affected by the day of the week that surgery is performed. Elective orthopaedic units should consider all means of maximising efficiency and lowering costs given the future challenges in service provision.

Pain Course after Total Knee Arthroplasty within a Standardized Pain Management Concept: A Prospective Observational Study

BACKGROUND

Joint replacement surgeries have been known to be some of the most painful surgical procedures. Therefore, the options for postoperative pain management are of great importance for patients undergoing total knee arthroplasty (TKA). Despite successful surgery, up to 30% of the patients are not satisfied after the operation. The aim of this study is to assess pain development within the first 4 weeks after TKA in order to gain a better understanding and detect possible influencing factors.

METHODS

A total of 103 patients were included in this prospective cohort study. Postoperative pain was indicated using a numeric rating scale (NRS). Furthermore, demographic data and perioperative parameters were correlated with the reported postoperative pain.

RESULTS

The evaluation of postoperative pain scores showed a constant decrease in the first postoperative week (mean NRS score of 5.8 on day 1 to a mean NRS score of 4.6 on day 8). On day 9, the pain increased again. Thereafter, a continuous decrease in pain intensity from day 10 on was noted (continuous to a mean NRS score of 3.0 on day 29). A significant association was found between postoperative pain intensity and gender, body mass index (BMI), and preoperative leg axis.

CONCLUSIONS

The increasing pain score after the first postoperative week is most likely due to more intensive mobilization and physiotherapy in the rehabilitation department. Patients that were female, had a low BMI, and a preoperative valgus leg axis showed a significantly higher postoperative pain scores. Pain management should consider these results in the future to improve patient satisfaction in the postoperative course after TKA.

Geographic Proximity of Family Members and Healthcare Utilization After Complex Surgical Procedures

OBJECTIVE

We sought to determine the relationship between a patient's proximal familial social support, defined as the geographic proximity of family members, and healthcare utilization after complex cardiovascular and oncologic procedures.

BACKGROUND

Social support mechanisms are increasingly identified as modifiable risk factors for healthcare utilization.

METHODS

We performed a retrospective cohort study of 60,895 patients undergoing complex cardiovascular procedures or oncologic procedures. We defined healthcare utilization outcomes as 30-day all-cause readmission unplanned readmission, nonindex hospital readmission, index hospital length of stay, and home discharge disposition. For each patient, we aggregated the number of first-degree relatives (FDR) living within 30 miles of the patient's home address at the time of the surgical procedure into the following categories: 0 to 1, 2 to 3, 4 to 5, 6+ FDRs. We developed hierarchical multivariable regression models to determine the relationship between the number of FDR living within 30 miles of the patient and the healthcare utilization outcomes.

RESULTS

Compared with patients with 0 to 1 FDRs, patients with 6+ FDRs living in close proximity had significantly lower rates of all-cause readmission (12.1% vs 13.5%, P <0.001), unplanned readmission (10.9% vs 12.0%, P =0.001), nonindex readmission (2.6% vs 3.2%, P =0.003); higher rates of home discharge (88.0% vs 85.3%, P <0.001); and shorter length of stay (7.3 vs 7.5 days, P =0.02). After multivariable adjustment, a larger number of FDRs living within 30 miles of the patient was significantly associated with a lower likelihood of all-cause readmission ( P <0.001 for trend), 30-day unplanned readmission ( P <0.001), nonindex readmission ( P <0.001); higher likelihood of home discharge ( P <0.001); and shorter index length of stay ( P <0.001).

CONCLUSIONS

The geographic proximity of family members is significantly associated with decreased healthcare utilization after complex cardiovascular and oncologic surgical procedures.

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.

The Impact of Surgeon Variability on Patient-Reported Outcomes in Total Hip Arthroplasty

BACKGROUND

Patient-related and surgery-related factors have been shown to be drivers of outcomes after total hip arthroplasty (THA); however, the impact of intersurgeon variability is poorly understood. The purpose of this study is to assess the following: (1) overall effect of surgeon on 1-year patient-reported outcome measures (PROMs), length of stay (LOS), discharge disposition, and 90-day readmission following THA; and (2) variability in 1-year PROMs among surgeons.

METHODS

A prospective cohort of 3,695 patients who underwent THA between 2016 and 2018 was included. Seventy-eight percent of patients completed 1-year follow-up. Thirty-one surgeons from a large healthcare system were included. Likelihood ratio tests analyzed the relationship among surgeon and 1-year Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, HOOS-Physical Function Short-Form, HOOS-Joint Replacement, University of California, Los Angeles activity score, Patient Acceptable Symptom State, LOS, discharge disposition, and 90-day readmission. Mixed-effect proportional odds and logistic regression models were used to determine variable importance for each outcome.

RESULTS

In total, 90.5% of patients responded positively to 1-year Patient Acceptable Symptom State. There was a significant association among surgeon and 1-year PROMs, LOS, discharge disposition (P < .001), and readmission (P = .002). For HOOS-Pain, Physical Function Short-Form, and Joint Replacement, surgeon (Akaike information criterion increase: 34.6, 18.7, 17.1, respectively) was a greater contributor to outcome than patient-level factors, including age, gender, and comorbidity. Differences in the highest and lowest median probability of achieving any given score on 1-year PROMs ranged from 11% to 18.5%. Variability was not explained by approach (P = .431) or case volume (correlation coefficient, ρ = 0.19).

CONCLUSION

Surgeon-level variability appears to be a greater driver of 1-year PROMs than some patient-level characteristics. Incorporating surgeon as a variable is beneficial for model-fitting and important for increasing value in THA.

Finding the optimal regimen for short-term daily recombinant human erythropoietin treatment for blood-saving purpose in patients undergoing unilateral primary total hip arthroplasty: a double-blinded randomized placebo-controlled trial

Purpose

To find the best short-term daily recombinant human erythropoietin (rhEPO)-based treatment protocols for blood-saving purpose in THA.

Method

The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150 IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 3 days preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily until 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total).

Results

One hundred eighty patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4 ± 11.4 g/L) than group C (103.9 ± 8.8 g/L). Group B (107.8 ± 8.4 g/L) also showed significantly higher Hb level than group C (103.9 ± 8.8 g/L) (p < 0.05). On postoperative day 3, no significant difference was found between group B and group C in Hb level (98.7 ± 10.5 and 94.9 ± 8.7 g/L, respectively) (p = 0.094), but the Hb level in group A (103.6 ± 11.0 g/L) was still markedly higher than in group B and the Hb level in group A was also markedly higher than in group C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3 ± 22.4, 84.6 ± 29.1, and 80.3 ± 23.9 ml, respectively) (p = 0.381), but on postoperative day one, the mean blood loss in group C (522.4 ± 189.4 ml) was significantly more than group B (371.2 ± 124.6 ml), and group B was also significantly more than group A (284.8 ± 112.9 ml) with 95% confidence interval, and group B had significantly less blood loss than group C (p < 0.001). With respect to the total blood loss, the total blood loss in group C (881.6 ± 314.9 ml) was significantly more than group B (642.6 ± 232.9 ml), and group B was also significantly more than group A (514.5 ± 204.6 ml) with 95% confidence interval (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable.

Conclusions

Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. However, surgeons should choose the regimen individually according to different patients’ personal circumstances.

Analgesic effect of perioperative duloxetine in patients after total knee arthroplasty: a prospective, randomized, double-blind, placebo-controlled trial

Background

To investigate the analgesic effect of perioperative use of duloxetine in patients received total knee arthroplasty (TKA).

Method

This prospective randomized, double-blind, placebo-controlled trial study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). 100 patients were finally enrolled. The hospital pharmacy prepared small capsules containing either duloxetine or starch (placebo) which were all identical in appearance and weight (50:50). The 100 enrolled patients were given a capsule (containing either 60 mg duloxetine or 60 mg placebo) every night before sleep since preoperative day 2 till postoperative day 14 (17 days in all) by a nurse who were not involved in this trial. Other perioperative managements were the same in the two groups. The primary outcome was the VAS score, including rVAS (visual analogue scale at rest) and aVAS (visual analogue scale upon ambulation) throughout the perioperative period. The secondary outcomes included opioid consumption, range of motion, including both active range of motion (aROM) and passive range of motion (pROM) and adverse events. The patients were followed up everyday until 7 days after TKA, afterwards, they were followed up at the time of 3 weeks and 3 months after TKA.

Result

rVAS in duloxetine group were significantly less than placebo group throughout the postoperative period: 4.7 ± 2.3 vs 5.9 ± 2.6 (P = 0.016) at 24 h postoperative; 2.1 ± 1.6 vs 2.8 ± 1.7 (P = 0.037) at 7 days postoperative. In terms of aVAS, similarly, duloxetine group had less aVAS than placebo group throughout the postoperative period: 6.2 ± 2.1 vs 7.1 ± 2.2 (P = 0.039) at 24 h postoperative; 3.3 ± 1.7 vs 4.1 ± 2.0 (P = 0.034) at 7 days postoperative. Patients in duloxetine group consumed significantly less opioids per day than the placebo group: 24.2 ± 10.1 g vs 28.5 ± 8.3 g (P = 0.022) at 24 h postoperative; 2.7 ± 2.5 g vs 4.1 ± 2.6 g (P = 0.007) at 7 days postoperative. aROM in duloxetine group were significantly better than placebo group until postoperative day 6, the aROM became comparable between the two groups: 110.2 ± 9.9° in duloxetine group vs 107.5 ± 11.5° in control group (P = 0.211). In terms of pROM, duloxetine group had significantly better pROM until postoperative day 5, the pROM became comparable between the two groups: 103.8 ± 12.1° in duloxetine group vs 99.5 ± 10.8° in control group (P = 0.064). No significant difference was found between the two groups in the rates of dizziness, bleeding, sweating, fatigue and dryness of mouth. In the placebo group, more patients got nausea/vomiting and constipation (P < 0.05). However, in terms of drowsiness, duloxetine group was reported higher rate (P < 0.05).

Conclusion

Several other RCTs have already mentioned the analgesic effect of duloxetine, but not in the immediate postoperative period. In this study, we found duloxetine could reduce acute postoperative pain in the immediate postoperative period and decrease the opioids consumption as well as accelerating postoperative recovery, without increasing the risk of adverse medication effects in patients undergoing TKA. Duloxetine could act as a good supplement in multimodal pain management protocol for patients undergoing TKA.

Trial registration statement

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). The date of registration was 06/16/2020.

Similar Efficacy of Arthroscopy and Arthrotomy in Infection Eradication in the Treatment of Septic Knee: A Systematic Review and Meta-Analysis

Aim: To compare the arthroscopy vs. arthrotomy for the treatment of native knee septic arthritis.

Methods: Electronic databases of PubMed, Embase and Cochrane Library were searched for eligible studies. Retrospective comparative studies comparing arthroscopy or arthrotomy for patients with septic arthritis of the native knee were eligible for this review. The primary outcome was recurrence of infection after first procedure. The secondary outcomes included hospital length of stay, operative time, range of motion of the involved knee after surgery, overall complications and mortality rate,

Results: Thirteen trials were included in this study. There were a total of 2,162 septic arthritis knees treated with arthroscopic debridement and irrigation, and 1,889 septic arthritis knees treated with open debridement and irrigation. Arthroscopy and arthrotomy management of the knee septic arthritis showed comparable rate of reinfection (OR = 0.85; 95% CI, 0.57–1.27; P = 0.44). No significant difference was observed in hospital length of stay, operative time and mortality rate between arthroscopy and arthrotomy management group, while arthroscopy treatment was associated with significantly higher knee range of motion and lower complication rate when compared with arthrotomy treatment.

Conclusion: Arthroscopy and arthrotomy showed similar efficacy in infection eradication in the treatment of native septic knee. However, arthroscopy treatment was associated with better postoperative functional recovery and lower complication rate.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

Objective

To verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.

Methods

We retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.

Results

All patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).

Conclusions

Elevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis

Purpose

Enhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint.

Methods

We selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study.

Results

After PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey.

Conclusion

The introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.

Influence of patellar denervation on anterior knee pain and knee function following total knee replacement: A systematic review and meta-analysis

BACKGROUND

Previous studies have reached mixed results regarding the effects of patellar denervation with electrocautery (PD) on total knee replacement (TKR). This systematic review and meta-analysis aimed to summarize all available literatures to investigate the influence of PD on postoperative anterior knee pain (AKP) and knee function after TKR.

METHODS

Electronic databases, including PubMed, Cochrane Library and Embase, were searched from their inception to March 2021. Randomized controlled trials (RCT) and quasi-randomized controlled trials (quasi-RCT) comparing PD and non-patellar denervation (NPD) in TKR were selected, and the Cochrane risk of bias tool was used to assess the quality of included trials. AKP prevalence was defined as the primary outcome.

RESULTS

A total of 12 RCTs and one quasi-RCT enrolled 1895 knees proved eligible. PD knees had significantly lower AKP prevalence than NPD knees (odds ratio [OR] = 0.54; 95% confidence intervals [95% CI], 0.36-0.81; p = 0.003). There was no difference between PD and NPD in terms of visual analogue scale for knee pain and range of motion, American knee society knee score, American knee society function score, patellar feller score, Oxford knee score for knee function. The results of subgroup analysis based on follow-up duration and patella resurfacing were in accordance with the results. PD knees were not associated with a higher risk of complication or revision.

CONCLUSION

PD can significantly reduce the AKP prevalence following TKR without increasing the risk of complication and revision. Although the pain relief effect of PD may not be associated with improved knee function after TKR, this procedure is preferred in both patella resurfacing and patella non-resurfacing TKR.

Duloxetine reduces pain after Total hip arthroplasty: a prospective, randomized controlled study

BACKGROUND

Previous studies have demonstrated the efficacy of duloxetine in reducing postoperative pain and opioid consumption. However, the effect of duloxetine on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of oral duloxetine in THA.

METHODS

We enrolled 96 patients in this randomized controlled trial. These patients were randomized (1,1) to either the duloxetine group or the placebo group and received daily doses of 60 mg duloxetine or placebo, respectively, from 2 d pre-operation to 14 d after surgery. The primary outcome was pain severity upon movement measured by a visual analogue scale (VAS). The secondary outcomes included VAS scores for resting pain, morphine consumption, Harris Hip Score, patient satisfaction at discharge, length of postoperative hospital stay, and adverse events.

RESULTS

Patients in the duloxetine group had significantly lower pain severity scores upon movement within 3 postoperative weeks (p < 0.05) while none of the differences met the minimum clinically important difference (MCID). Moreover, patients in the duloxetine group performed better in terms of resting pain (in 3 weeks after surgery), morphine requirements, and satisfaction level at discharge (all p < 0.05). There was no difference between groups in the prevalence of adverse events.

CONCLUSIONS

Although it did not result in a clinically meaning reduction in pain after total hip arthroplasty, perioperative administration of 60 mg of duloxetine daily significantly alleviated pain in the postoperative 3 weeks and morphine requirements during the postoperative 48 h. Therefore, duloxetine still shows promise in optimizing the multimodal pain-management protocols in total hip arthroplasty.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000033606 , 06/06/2020.

The Impact of Room-Sharing on Length of Stay After Total Hip or Knee Arthroplasty: A Retrospective Study

Background

Prolonged length of stay (LOS) after elective total hip (THA) and knee (TKA) arthroplasty is often associated with worse patient outcomes. Social support through room-sharing has been identified as a factor that may reduce LOS in a hospital setting, but has not yet been examined in an orthopedic population. The aim of this study was to evaluate the effect of single- vs shared-room accommodation after elective TKA or THA on hospital LOS.

Method

A retrospective study was conducted using data from hospital medical records at our institution. Patients receiving unilateral, elective THA or TKA over a 2-year period were eligible. Patients were allocated to either a single room or four-bed shared room. The primary outcome was LOS; secondary outcomes included complications, discharge destination, and return to operating theater.

Results

One hundred eighty-five patients (70 THA, 115 TKA; mean age 65.74 ± 10.38, 59% female) were included, of whom 82 were allocated to a single room and 103 to a shared room. There was no statistically significant difference in LOS between the 2 groups (5.18 ± 2.21 days [single] vs 4.88 ± 2.12 days [shared]; mean difference −0.29 [95% CI −0.92-0.33], P = .36). Analysis modeling for multiple confounders found no association among room allocation, LOS, and discharge destination. However, more patients in single rooms required discharge to rehabilitation (27% vs 9%) and return to theater (7% vs 1%).

Conclusions

Room allocation did not correlate with a difference in LOS in patients undergoing elective THA or TKA.

Patellar Denervation with Electrocautery Reduces Anterior Knee Pain within 1 Year after Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The effect of patellar denervation with electrocautery (PD) on anterior knee pain (AKP) after total knee arthroplasty (TKA) is still debated. The aim of this meta-analysis was to evaluate the current evidence regarding the use of PD in TKA without patellar resurfacing.

METHODS

A computerized search of published studies was performed in the PubMed, Embase and Cochrane Library databases in December 2019. Eligible studies were randomized controlled trials (RCTs) comparing clinical outcomes of the PD group and the non-PD group. Subgroup analyses were carried out according to the follow-up time (3, 12 months, and over 12 months) to evaluate whether the clinical effect of PD changed with time.

RESULTS

Ten RCTs were included in this meta-analysis. Pooled results showed a lower rate of AKP (Risk Ratio [RR] = 0.70; 95% confidence interval [CI], 0.50 to 0.97; P = 0.03) and a reduction in visual analogue scale (VAS) for AKP (mean difference, -0.37; 95% CI, -0.69 to -0.05; P = 0.02) in the PD group when compared to the non-PD group. Subgroup analyses found the differences in AKP incidence and VAS for AKP were significant at 3- and 12-month follow-up but not after 12-month follow-up. No significant difference was observed in functional scores between the two groups. No specific complication directly or indirectly related to PD was found.

CONCLUSION

PD can decrease the incidence and severity of AKP within 12 months after TKA, but the effect cannot be maintained after 12-month follow-up. Without significant associated complication and reoperation, the use of PD is still recommended in TKA without patellar resurfacing.

Traumatic Obturator Dislocation of the Hip Joint Associated with Greater Trochanter Fracture: A Case Report

Background

Traumatic obturator dislocation of the hip joint associated with greater trochanter fracture is a rare injury. We used the lateral approach through the rectus abdominis to remove the femoral head dislocated into the obturator, and the posterolateral approach was used for reduction and internal fixation of the femoral greater trochanteric fracture and total hip replacement (THR). Good follow‐up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury.

Case Report

The patient was hospitalized due to a traffic accident that resulted in the patient experiencing swelling and deformity accompanied by limited mobility of the left hip and left knee.

X‐ray examination and CT confirmed that the patient suffered from left hip obturator dislocation, greater trochanter fracture, pelvic fracture (Tile B), left acetabular fracture, right open tibiofibular comminuted fracture (Gustilo III), and posterior urethral injury.

The femoral head was removed from the pelvic cavity through a pararectus approach under general anesthesia. A posterolateral approach was used for open reduction, and cable internal fixation for the left intertrochanteric fracture and uncemented THR were performed.

Results

The ability to work was restored 6 months after the operation. The Harris hip score, reflecting joint function, was 86 points after 2 years of follow‐up observation.

Conclusion

A lateral approach of rectus abdominis to remove the dislocated femoral head in the pelvis from the obturator should be selected, along with the posterolateral approach for reduction and internal fixation of the intertrochanteric fracture and THR. This case also provides a new reference for the treatment of this type of hip fracture dislocation.

Optimal Handling of the Patella in Tourniquet-Free Total Knee Arthroplasty: Eversion or Lateral Retraction?

Objective

To explore the optimal handling of the patella during total knee arthroplasty (TKA) without the intraoperative application of a tourniquet.

Methods

A total of 104 patients undergoing primary unilateral TKA without the intraoperative use of tourniquets from December 2018 to March 2019 in our center were included in this prospective randomized double‐blinded study, including 42 men and 62 women with a mean age of 66.3 ± 7.8 years and a minimum follow‐up of 1 year. Patients were randomly divided into an eversion group (n = 52) and a retraction group (n = 52) based on the intraoperative handling of the patella (eversion or lateral retraction). Primary outcome measures, including the visual analog scale at rest (rVAS) and the visual analog scale in motion (mVAS) for both anterior knee pain and thigh pain, opioid consumption, active range of motion (aROM), passive range of motion (pROM), the time needed for return of the straight‐leg raise (SLR), and 90° knee flexion, were recorded by an independent observer, who also noted secondary outcome measures, including operation time, length of stay (LOS), patella‐related (patellar tilt and baja) and other complications, knee swelling, Hospital for Special Surgery (HSS) scores, and the 12‐item Short Form Health Survey (SF‐12) scores.

Results

There were no significant differences between the two groups in terms of baseline parameters. At 24, 48, and 72 h postoperatively (PO), patients in the eversion group experienced more severe thigh pain than those in the retraction group (24 h: 2.6 ± 0.8 vs 2.2 ± 0.5 [P = 0.003]; 48 h: 2.0 ± 0.5 vs 1.8 ± 0.4 [P = 0.026]; 72 h: 1.1 ± 0.4 vs 0.9 ± 0.5 [P = 0.012], respectively) and consumed more opioids (24 h: 22.3 ± 7.7 vs 15.1 ± 8.9 mg [P < 0.001]; 48 h: 27.3 ± 9.3 vs 21.4 ± 10.5 mg [P = 0.003]; 72 h: 23.1 ± 8.2 vs 19.8 ± 7.6 mg [P = 0.036], respectively), but no significant difference was found in anterior knee pain (both rVAS and mVAS) preoperatively or at 24, 48 or 72 h, 3 weeks, 2 or 6 months, or 1 year PO (P > 0.05). Throughout the 1‐year follow‐up, patients in the retraction group showed significantly better function, including greater aROM and pROM at all time points (P < 0.05) and a shorter period of time needed for return to SLR (1.9 ± 0.7 vs 2.2 ± 0.8 days [P = 0.044]) and 90° knee flexion (1.2 ± 0.7 vs 1.9 ± 0.8 days [P < 0.001]). In addition, no between‐group difference was found in operation time, complication rate, swelling of the knee, or SF‐12 score during the follow‐up period (P > 0.05). The eversion group had a significantly longer LOS (5.61 ± 1.92 vs 4.93 ± 1.45 days [P = 0.044]) and worse HSS score within 2 months PO (3 weeks PO: 77.4 ± 7.6 vs 81.7 ± 7.2 [P = 0.004]; 2 months PO: 85.1 ± 7.2 vs 88.5 ± 6.1 [P = 0.011]), but at the third follow‐up (6 months PO), the HSS score in the two groups became comparable (P > 0.05). No patellar tilt occurred in either group and there was only one case of patellar baja in the eversion group, with no significant between‐group difference (P > 0.05).

Conclusion

We recommend lateral retraction rather than eversion for optimal handling of the patella during TKA because the postoperative functional recovery is better and thigh pain is relatively less severe.

[Safety and effectiveness of total hip arthroplasty in patients with hypothyroidism]

Objective

To evaluate the safety and effectiveness of total hip arthroplasty (THA) in patients with hypothyroidism.

Methods

Sixty-three patients with hypothyroidism (hypothyroidism group) and 63 euthyroid patients without history of thyroid disease (control group) who underwent primary unilateral THA between November 2009 and November 2018 were enrolled in this retrospective case control study. There was no significant difference between the two groups in gender, age, body mass index, hip side, reason for THA, American Society of Anesthesiology (ASA) classification, preoperative hemoglobin (Hb) level, and preoperative Harris score ( P>0.05). The perioperative thyroid stimulating hormone (TSH) and thyroxine (T ₄) levels, the hypothyroidism-related and other complications during hospitalization, the decrease in Hb, perioperative total blood loss, blood transfusion rate, length of hospital stays, and 90 days readmissions rate in the two groups were recorded and evaluated. The periprosthetic joint infection, aseptic loosening of the prosthesis, and hip Harris score during follow-up were recorded.

Results

The differences in the TSH and T ₄ of hypothyroidism group between pre- and 3 days post-operation were significant ( P>0.05) and no hypothyroidism-related complications occurred after THA. The decrease in Hb and perioperative total blood loss in the hypothyroidism group were significantly higher than those in the control group ( P<0.05), but there was no significant difference between the two groups in terms of transfusion rate, length of hospital stays, and 90 days readmission rates ( P>0.05). No significant difference in the rate of complications (liver dysfunction, heart failure, pulmonary infection, urinary infection, and wound complication) between the two groups was found ( P>0.05) except for the rate of intramuscular vein thrombosis which was significantly lower in the hypothyroidism group, and the rate of postoperative anemia which was significantly higher in the hypothyroidism group ( P<0.05). The two groups were followed up 1.0-9.9 years (mean, 6.5 years). At last follow-up, Harris score in both groups were significantly higher than those before operation ( P<0.05). An increase of 39.5±12.3 in hypothyroidism group and 41.3±9.3 in control group were recorded, but no significant difference was found between the two groups ( t=0.958, P=0.340). During the follow-up, 1 case of periprosthetic joint infection occurred in the hypothyroidism group, no loosening or revision was found in the control group.

Conclusion

With the serum TSH controlled within 0.5-3.0 mU/L and T ₄ at normal level preoperatively, as well as the application of multiple blood management, hypothyroid patients can safely go through THA perioperative period and effectively improve joint function, quality of life, and obtain good mid-term effectiveness.

A propensity score-matched analysis between patients with high hip dislocation after childhood pyogenic infection and Crowe IV developmental dysplasia of the hip in total hip arthroplasty with subtrochanteric shortening osteotomy

BACKGROUND

Whether satisfactory clinical and radiological outcomes of total hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) in high hip dislocation after childhood pyogenic infection can be achieved as in Crowe IV developmental dysplasia of the hip (DDH) remains unclear.

METHODS

Between September 2009 and December 2016, 151 primary THAs performed at our institution using similar SSO technique and prosthetic design were retrospectively reviewed. After excluding patients who met exclusion criteria, 29 patients were identified as high dislocation (Crowe IV) after childhood infection (HDACI) and 107 as Crowe IV developmental dysplasia of the hip (DDH). Propensity score matching was used to select 29 Crowe IV DDH patients as a control group for the HDACI group with comparable preoperative conditions. Clinical and radiological outcomes and complication were compared and analyzed. The mean follow-up duration of the 2 groups was 5.0 years.

RESULTS

The mean Harris hip score (HHS) and the mean score in range of motion (ROM) domain of the modified Merle d'Aubigné-Postel (MAP) were 84.6 and 4.5 in the HDACI group, compared with 88.3 and 4.9 in the DDH group; there was significant difference between the 2 groups in these parameters (P = 0.015 and 0.035, respectively). Meanwhile, in the HDACI group, the median time of osteotomy union was 4 months and osteotomy nonunion rate was 3%; no significant difference was detected in the median time of osteotomy union and osteotomy nonunion rate between the 2 groups (P = 0.388 and 1.000, respectively). And no significant difference was found in the rate of complications between two groups.

CONCLUSIONS

HDACI patients who received THA combined with SSO could achieve similar satisfactory results as DDH patients in Crowe type IV. The fixation technique of autogenous cortical bone struts had a positive influence on osteotomy healing of SSO in this specific setting.

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.

Does well-controlled overt hypothyroidism increase the risk of total knee arthroplasty?

BACKGROUND

Overt hypothyroidism is widely accepted as a risk factor for adverse events following total knee arthroplasty (TKA). However, no prior study has preoperatively reversed hypothyroidism and reevaluated its risk. This retrospective study aimed at investigating whether well-controlled overt hypothyroidism would still increase the risk of TKA.

METHODS

Between November 2009 and November 2016, patients diagnosed with overt hypothyroidism but well controlled and underwent TKA were compared with euthyroid TKA patients. Data were extracted from our departmental database. Chi-squared test and t-tests were used for comparisons.

RESULTS

Hypothyroid patients had more blood loss and lower postoperative haemoglobin (Hb) and haematocrit level than the control group (all P < 0.05). Although the postoperative anaemia rate was lower in the control group (P = 0.01), there was no significant difference in the transfusion rate between the two groups (2.99% versus 7.46%, P = 0.10) or in the rates of other complications (P > 0.05). Interestingly, intramuscular venous thrombosis rate in hypothyroid patients was significantly lower than that in the control group (1.49% versus 9.70%, P = 0.00). Clinical outcome scores were comparable between the two groups throughout the course. And only one case of infection occurred in the hypothyroid patients.

CONCLUSION

Well-controlled overt hypothyroidism did not increase the risk of TKA, except for perioperative blood loss. Surgeons should be aware that even if hypothyroidism is reversed, the risk of more perioperative blood loss still exists and that, consequently, perioperative blood management is still essential in this population.

Bone restoration after revision hip arthroplasty with femoral bone defects using extensively porous-coated stems with cortical strut allografts

Background

Stress shielding and bone loss of the femur are of great concern after revision total hip arthroplasty (THA) with extensively porous-coated stems, especially in a femur with already bone loss. The femoral bone remodeling patterns after revision THA with femoral bone defects using extensively porous-coated stems with cortical strut allografts remain unclear.

Methods

We retrospectively reviewed 47 patients who underwent revision THA using extensively porous-coated stems combined with cortical strut allografts and 75 patients without allografts. The minimum follow-up was 2 years. Femoral bone remodeling signs, including stress shielding, bone restoration in bone defect area, distal cortical hypertrophy, and femoral width, were compared between patients with and without cortical strut allografts. Clinical outcomes were also compared between two groups.

Results

Patients with cortical strut allografts showed less severe stress shielding (P = 0.01) than patients without allografts. Patients with allografts had more osseous restoration in bone defect area than patients without allografts (63.8% vs 30.7%, P < 0.001). Femoral width was significantly higher in femur with allografts than in femur without allografts at the immediate postoperative stage and latest follow-up (both P < 0.001). The hip function score, re-revision rate, and complications were comparable between two groups.

Conclusion

The application of cortical strut allografts can decrease the severity of stress shielding, augment osseous restoration in bone defect area and improve femoral bone stock after revision THA using extensively porous-coated stems.

Minimum 8-year follow-up of revision THA with severe femoral bone defects using extensively porous-coated stems and cortical strut allografts

Background

Revision total hip arthroplasty (THA) with severe femoral bone defects remains a major challenge. The purpose of this study is to report the minimum 8-year clinical and radiographic results of revision THA with severe femoral bone defects treated with extensively porous-coated stems and cortical strut allografts.

Methods

We retrospectively identified 44 patients diagnosed with Paprosky type III and IV femoral bone defects between January 2006 and July 2011. The exclusion criteria were patients not eligible for surgery, revised with extensively porous-coated stems alone, lost to follow-up and deceased. A total of 31 patients treated with extensively porous-coated stems and cortical strut allografts were finally included in this study. The degree of femoral bone defects was categorized as Paprosky type IIIA in 19 patients, type IIIB in 9 patients and type IV in 3 patients. The mean duration of follow-up was 11.0 ± 1.5 (range, 8.1–13.5) years.

Results

The mean Harris Hip Score improved significantly from 43.4 ± 10.5 points to 85.2 ± 6.6 points (P < 0.001). Similarly, WOMAC and SF-12 scores also significantly improved. Twenty-eight stems achieved stable bone ingrowth, two stems showed stable fibrous ingrowth, and one stem was radiologically unstable. Complete union and bridging between cortical strut allografts and host bone was achieved in all 31 patients. The femoral width was augmented with cortical strut allografts after revision surgery (an increase of 10.5 ± 0.5 mm) and showed a slight decrease of 2.5 ± 4.8 mm after the 10-year follow-up. Using re-revision for any reason as an endpoint, the Kaplan-Meier cumulative survival rate of the stem was 96.2% (95% confidence interval, 75.7–99.5%) at 10 years.

Conclusion

Our data demonstrate that the use of extensively porous-coated stems combined with cortical strut allografts in revision THA with Paprosky type III and IV femoral bone defects can provide satisfactory clinical and radiographic outcomes with a minimum follow-up of 8 years.

Risk of Dislocation After Total Hip Arthroplasty in Patients with Crowe Type IV Developmental Dysplasia of the Hip

Objective

To investigate whether the risk of dislocation after total hip arthroplasty (THA) in patients with Crowe type IV developmental dysplasia of the hip (DDH) is high and to further identify the risk factors for postoperative dislocation in these patients.

Methods

This retrospective cohort study reviewed Crowe type IV DDH patients undergoing THA between January 2009 and December 2017 in our institution. Each Crowe type IV DDH patient was matched with three Crowe type I, II, or III DDH patients according to gender, side and date of operation. The primary outcome of this study was postoperative dislocation after THA. Occurrence, rate, classification, treatment and outcome of dislocation were documented in detail for all patients. The dislocation rates were compared between Crowe type IV DDH patients and Crowe type I, II, or III DDH patients. Demographic data, implant factors, and surgical factors were compared between the dislocation and no dislocation groups. Multiple logistic regression analysis was used to determine the independent risk factors for dislocation in Crowe type IV hips.

Results

A total of 131 Crowe type IV hips were followed up for a mean of 76.5 ± 28.1 months. Three hundred and ninety‐three Crowe type I, II and III hips, including 261 type I hips, 94 type II hips, and 38 type III hips, were identified as controls and followed up for a mean of 76.4 ± 28.2 months. No significant difference was observed in follow‐up time between two groups (P = 0.804). One or more dislocations occurred in 22 of the 524 dysplasia hips (4.20%). Of the 22 dislocated hips, 20 hips (90.9%) were successfully managed with non‐operative treatment. Two patients (9.1%, one Crowe type I and one Crowe type IV) experienced recurrent dislocation and required revision surgery. Crowe type IV hips had a significantly higher postoperative dislocation rate than type I, II, and III hips (11.45% vs 1.78%, P < 0.001). The use of a 22‐mm femoral head (odds ratio [OR] = 23.55, 95% confidence interval [CI] = 1.901–291.788, P = 0.014), older age (OR = 1.128, 95% CI = 1.037–1.275, P = 0.031), and absence of false acetabulum (OR = 12.425, 95% CI = 1.982–77.879, P = 0.007) were identified as independent risk factors for dislocation in Crowe type IV hips.

Conclusions

Crowe type IV DDH patients were at a high risk of dislocation after THA, and using large femoral heads and improving abductor muscle strength may help decrease the rate of postoperative dislocation in such patients.