Activity levels and return to work after revision total hip and knee arthroplasty in patients under 65 years of age

Unplanned Emergency Department Visits Following Revision Total Joint Arthroplasty: Incidences, Risk Factors, and Mortalities

BACKGROUND

The incidence of unplanned emergency department (ED) visits following revision total joint arthroplasty is an indicator of the quality of postoperative care. The aim of this study was to investigate the incidences, timings, and characteristics of ED visits within 90 days after revision total joint arthroplasty.

METHODS

A retrospective review of 457 consecutive cases, including 254 revision total hip arthroplasty (rTHA) and 203 revision total knee arthroplasty (rTKA) cases, was conducted. Data regarding patient demographics, timings of the ED encounter, chief complaints, readmissions, and diagnoses indicating reoperation were analyzed.

RESULTS

The results showed that 41 patients who had rTHA (16.1%) and 14 patients who had rTKA (6.9%) returned to the ED within 90 days postoperatively. The incidence of ED visits was significantly higher in the rTHA group than in the rTKA group (P = .003). The most common surgery-related complications were dislocation among rTHA patients and wound conditions among rTKA patients. Apart from elevated calculated comorbidity scores, peptic ulcer in rTHA patients and cerebral vascular events and chronic obstructive pulmonary disease in rTKA patients might increase chances of unplanned ED visits. Patients who had ED visits showed significantly higher mortality rates than the others in both rTHA and rTKA cohorts (P = .050 and P = .008, respectively).

CONCLUSIONS

The ED visits within 90 days are more common after rTHA than after rTKA. Patients in both ED visit groups after rTHA and rTKA demonstrated worse survival. Efforts should be made to improve quality of care to prevent ED visits.

Long-term survival and complication rate of cementless prosthetic stems in primary total hip arthroplasty categorized by types according to Mont classification: a regional registry-based study on 53,626 implants

INTRODUCTION

The purpose of this retrospective registry-based study is to assess survival and causes of failure of cementless stem implants used in total hip arthroplasty (THAs), to ascertain if there are differences when these are categorized according to the six types described by Mont.

METHODS

Data collected from the regional registry regarding all primary THAs performed from 2000 to 2019 were analyzed. Femoral prosthetic stems were divided into the six types of Mont classification. For each stem type, number of implants, survival and causes of failure were evaluated and compared.

RESULTS

The most frequently implanted stem type was the 3c type (53.4%). Type 1 had the lowest stem failure rate (1.6%), and type 6 showed the highest (3.9%). Periprosthetic fracture was the most frequent complication in type 6, accounting for 34.5% of failures. Aseptic loosening was the main complication in type 2 stems, accounting for 36.4% of failures. Pairwise comparisons showed significant higher survival of type 1 compared to type 3c (p = 0.000026) and type 6 (p = 0.000076), and between type 3a compared to type 3c (p = 0.03) and type 6 (p = 0.026).

CONCLUSION

Significant variations in implant survival rates were found among the six Mont-types of cementless stems. These findings emphasize the paramount importance of stem design and fixation area in determining long-term survival, providing a guidance for orthopedic surgeons in the selection of the most appropriate stem for primary THA, contributing to our understanding of cementless stem performance, presenting invaluable insights to further improve patient outcomes in THA surgery.

Return to work following revision knee arthroplasty in patients under 65 years of age: A retrospective study

Background

Little is known about employment following revision total knee arthroplasty (RTKA). This study aims to describe factors associated with returning to employment in patients of working age who underwent RTKA surgery.

Methods

We performed a retrospective assessment of all patients aged ≤65 who underwent RTKA at our NHS institution between 2006 and 2020. All indications and revision procedures were included. Pre-operative demographics, indication for surgery and Oxford Knee Scores (OKS) were recorded. Postal questionnaires were sent to patients including patient reported outcome measures and a departmental questionnaire asking patients about employment status pre- and post-operatively.

Results

132 procedures were performed in 113 patients. Median follow up was 5.5 years (2.4-9.0). Mean age was 58 (5.8) and 50% (57) were men. 62 patients undergoing 74 procedures responded to postal questionnaires and were included in the study. 53% (33) were employed prior to surgery and 61% (38) returned to work at a median of 12 weeks (3-150). Of the 24 who did not return to work, 7 reported intending to return to work. Those patients who returned to work had increased pre-operative OKS (16.9 vs 13.6) and mean improvement (16.5 vs 12.4).

Conclusion

This study is limited by small numbers and its observational nature. In this population the majority of patients who wished to return to work after RTKA were able to do so. This provides some reassurance when counselling patients. Prospective studies to better understand the factors that predict return to work will be important with increasing demands from surgery.

Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty?

BACKGROUND

With the increasing number of young patients undergoing primary total knee arthroplasty (TKA), there will be an increase in the number of patients who require revision. While the results of TKA in younger patients are well known, there is little information regarding to the outcomes of revision TKA in this population. The purpose of this study was to evaluate the clinical outcomes in patients <60 years of age undergoing aseptic revision TKA.

METHODS

We retrospectively reviewed 433 patients undergoing aseptic revision TKA between 2008 and 2019. There were 189 patients <60 years compared to a group of 244 patients >60 years undergoing revision TKA for aseptic failures in terms of implant survivorships, complications, and clinical outcomes. Patients were followed for a mean of 48 months (range, 24 to 149).

RESULTS

A total of 28 (14.8%) patients less than 60 years of age required repeat revision compared to 25 (10.2%) 60 years or older (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.73-5.22, P = .187). There were no differences regarding postprocedural Patient-Reported Outcomes Measurement Information System (PROMIS) physical health scores (72.3 ± 13.7 versus 72.0 ± 12.0, P = .66) and PROMIS mental health scores (66.6 ± 17.4 versus 65.8. ± 14.7, P = .72), at an average of 32.9 and 30.7 months, respectively. Postoperative infection occurred in 3 (1.6%) patients <60 years of age, while 12 (4.9%) postoperative infections occurred in patients 60 years or older (OR 0.75, 95% CI 0.06-10.2, P = .83).

CONCLUSION

There were no statistically significant differences in clinical outcomes between patients <60 versus > 60 years of age undergoing aseptic revision TKA.

Mid-term outcomes of revision hip arthroplasty due to titanium modular neck failure

INTRODUCTION

The current strategy for modular neck failures in total hip arthroplasty (THA) is calibrated on CrCo neck failures. Stem revision is usually required, but the procedure is challenging and achieves modest outcomes (up to 20% of re-revisions at short-term). No study reports revision strategies and outcomes after Ti neck failures. Aims of the study were to evaluate: (1) demographic and implant features of the cohort to be revised, (2) intra-operative findings and surgical revision strategies and (3) clinical and radiological post-revision outcomes.

MATERIALS AND METHODS

Hospital database was enquired about revisions due to Ti neck failures in primary THAs. Sixty-five revisions were enrolled (all with the same modular system). Neck exchange was attempted as the first-line treatment. Patients were clinically and radiographically evaluated after revision.

RESULTS

The revision cohort encompassed fatigue neck fractures occurred 4.4 ± 2.6 years after THA: patients < 65 years and/or > 80 kg (98.5%) were predominant. Fifty-three neck exchanges were performed (81.5%). Eleven failures required stem revisions (16.9%), generally due to demanding neck extraction. Six complications occurred after neck exchange (11.3%), among them 2 acute infections requiring surgery (3.8%). Among stem revisions, one aseptic loosening and one neck re-fracture (18.5%) required re-revisions. At a mean follow-up of 7.1 ± 4 years, the neck exchange cohort achieved a mean HHS of 89.1 ± 6.3 (stem revisions: 84.1 ± 10.9).

CONCLUSIONS

Revisions for Ti neck failures were predominantly performed due to fatigue fractures. In case of failures, neck exchange is a feasible procedure in most of the cases, with good outcomes at 7 years.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Beyond type III Paprosky acetabular defects: are partial pelvic replacements with iliosacral fixation successful?

PURPOSE

Supra-acetabular bone loss close beyond the sciatic notch is one of the most challenging defect types for stable anatomical reconstruction in revision arthroplasty. Using reconstruction strategies from tumour orthopaedic surgery, we adapted tricortical trans-iliosacral fixation options for custom-made implants in revision arthroplasty. The aim of the present study was to present the clinical and radiological results of this extraordinary pelvic defect reconstruction.

METHODS

Between 2016 and 2021, 10 patients with a custom-made pelvic construct using tricortical iliosacral fixation (see Fig. 1) were included in the study. Follow-up was 34 (SD 10; range 15-49) months. Postoperatively CT scans evaluating the implant position were performed. Functional outcome and the clinical results were recorded.

RESULTS

Implantation was possible as planned in all cases in 236 (SD 64: range 170-378) min. Correct centre of rotation (COR) reconstruction was possible in nine cases. One sacrum screw crossed a neuroforamen in one case without clinical symptoms. During the follow-up period, four further operations were required in two patients. There were no individual implant revisions or aseptic loosening recorded. The Harris Hip Score increased significantly from 27 Pts. to 67 Pts. with a mean improvement of 37 (p < 0.005). EQ-5D developed from 0.562 to 0.725 (p = 0.038) as a clear improvement in quality of life.

CONCLUSION

Custom-made partial pelvis replacement with iliosacral fixation offers a safe solution in "beyond Paprosky type III defects" for hip revision arthroplasty. Due to meticulous planning, precise implantation with good clinical outcome can be achieved. Furthermore, the functional outcome and patient satisfaction increased significantly showing promising early results with a relatively low complication rate.

Physical activity after revision knee arthroplasty including return to sport and work: a systematic review and meta-analysis including GRADE

BACKGROUND

The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work.

METHODS

A search was conducted in the databases Medline and Embase until February 24^th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234).

CONCLUSIONS

The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low.

LEVEL OF EVIDENCE

Level 3.

Time for return to sport following total hip arthroplasty: a meta-analysis

INTRODUCTION

Total Hip Arthroplasty (THA) is being increasingly undertaken in younger and more active patients, with many of these patients wanting to return to sport (RTS) after surgery. However, the percentage of patients RTS and time at which they are able to get back to sport following surgery remains unknown. The objective of this meta-analysis was to determine the time patients RTS after THA.

METHODS

A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on THA and RTS, in the English language, published from the inception of the database to October 2020. All clinical trials reporting on to RTS following THA were included. Data relating to patient demographics, methodological quality, RTS, clinical outcomes and complications were recorded. The PRISMA guidelines were used to undertake this study.

RESULTS

The initial literature search identified 1720 studies. Of these, 11 studies with 2297 patients matched the inclusion criteria. 3 studies with 154 patients demonstrated an overall pooled proportion of 40.0% (95% CI, 32.5-47.9%) of patients RTS between 2 and 3 months after surgery. 4 studies with 242 patients demonstrated an overall pooled proportion of 76.9% (95% CI, 71.5-82.0) of patients RTS by 6 months after surgery. Pooled proportion analysis from 7 trials with 560 patients demonstrated 93.9% (95% CI, 82.7-99.5%) of patients RTS between 6 and 12 months after surgery.

CONCLUSIONS

Pooled proportion analysis showed increasingly more patients were able to RTS after THA over the first 1 year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 90% of patients were able to RTS at 6-12 months after THA. These finding will enable more informed discussions between patients and healthcare professionals about time for RTS following THA.

Burden and Characteristics of Revision Total Knee Arthroplasty in China: a National Study Based on Hospitalized Cases

BACKGROUND

National epidemiological data in China are absent for revision total knee arthroplasty (TKA). This study aimed to investigate the burden and characteristics of revision TKA in China.

METHODS

We reviewed 4,503 revision TKA cases registered in the Hospital Quality Monitoring System in China between 2013 and 2018 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Revision burden was determined by the ratio of the number of revision procedures to the total number of TKA procedures. Demographic characteristics, hospital characteristics, and hospitalization charges were identified.

RESULTS

The revision TKA cases accounted for 2.4% of all TKA cases. The revision burden showed an increasing trend from 2013 to 2018 (2.3 to 2.5%) (P for trend = 0.034). Gradual increases in revision TKA were observed in patients aged > 60 years. The most common causes for revision TKA were infection (33.0%) and mechanical failure (19.5%). More than 70% of the patients were hospitalized in provincial hospitals. A total of 17.6% patients were hospitalized in a hospital outside the province of their residence. The hospitalization charges continued to increase between 2013 and 2015 and remained roughly stable over the next three years.

CONCLUSIONS

This study provided epidemiological data for revision TKA in China based on a national database. There was a growing trend of revision burden during the study period. The focalized nature of operations in a few higher volume regions was observed and many patients had to travel to obtain their revision procedure.

[Postoperative outcomes and survival rates after aseptic revision total hip arthroplasty : What can patients expect from revision surgery?]

BACKGROUND

In 2020, more than 14,000 aseptic revision procedures for total hip arthroplasty (THA) were registered in Germany. Patient expectations of revision hip arthroplasty are not substantially different from expectations of primary hip replacement.

OUTCOME

However, revision surgery is associated with increased complication rates and a higher proportion of dissatisfied patients. In particular, poorer postoperative function and mobility as well as increased pain levels following revision THA have been described compared to the outcome after primary THA. Quality of life and return-to-work can also be impaired.

SURVIVAL RATE

Implant survival is influenced by age, BMI, and comorbidities of the patients, but also by the size and complexity of bone defects, the extent of periprosthetic soft tissue compromise and the choice of revision implant(s). In addition, the number of previous revision surgeries inversely correlates with the survival rates. Previous revisions have been shown to be associated with increased risks of aseptic loosening, instability and periprosthetic infection.

Early Total Hip Arthroplasty is a Cost-Effective Treatment for Severe Radiographic Slipped Capital Femoral Epiphysis Over an Individual's Lifetime

BACKGROUND

Slipped capital femoral epiphysis (SCFE) causes degenerative changes warranting total hip arthroplasty (THA) in approximately 50% of patients by age 60 years. For severe SCFE, a reorienting intertrochanteric osteotomy (ITO) following in situ pinning (ISP) can decrease impingement with hip flexion, but by altering proximal femoral geometry, complicates subsequent conversion THA. We hypothesized that increasing implant survivorship would affect the most cost-effective treatment strategy (ISP followed by ITO [ISP + ITO] with later THA versus ISP alone [ISPa] with earlier THA) over a patient's lifetime.

METHODS

A state-transition Markov model was constructed to analyze the cost-effectiveness of either ISPa or ISP + ITO over a 60-year time horizon for children who have severe, stable SCFE. Transition probabilities associated with implant and native hip survivorship, state utilities, and costs were derived from the literature. Sensitivity analyses assessed the model robustness. Incremental cost-effectiveness ratios (ICERs) were compared to a societal willingness to pay (WTP) of $100,000 per quality-adjusted life year (QALY).

RESULTS

Over a 60-year horizon, ISPa was costlier ($291,836) than ISP + ITO ($75,227) but achieved overall better outcomes (51.4 QALYs ISPa versus 48.7 QALYs ISP + ITO), rendering ISPa cost-effective with an ICER of $80,980/QALY. Implant survivorship and time horizon were sensitive variables.

CONCLUSION

Based upon current implant performance, ISPa with subsequent earlier THA is cost-effective when considering an individual's life expectancy and thereby deserves consideration in patients who have severe SCFE. Without clear level 1 clinical data, our economic model considers a difficult problem, while providing families and clinicians with a framework for understanding treatment options.

LEVEL OF EVIDENCE

Economic and decision analysis, Level III.

A meta-analysis assessing time for return to sport following hip resurfacing

BACKGROUND

Hip resurfacing arthroplasty (HRA) is associated with excellent functional outcomes and return to pre-disease level of activity. The time for return to sport (RTS) following HRA remains unknown. The aim of this meta-analysis was to establish the time for RTS following HRA.

METHODS

A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on HRA and RTS, in the English language, published from the inception of the database to October 2020. In addition, a manual search was performed of relevant sports medicine and orthopaedic journals, and the bibliographies reviewed for eligible trials. All clinical trials reporting on time to RTS following HRA were included. Data relating to patient demographics, methodological quality, operation type, RTS, clinical outcomes, and complications were recorded by two independent reviewers. The PRISMA guidelines for reporting meta-analyses was used to undertake this study.

RESULTS

The initial literature search identified 1559 studies and nine further studies were found. Of these, 11 studies with a total of 659 patients matched the inclusion criteria. Two studies involving a total of 94 patients demonstrated an overall pooled proportion of 91.8% (95% CI 71.8-100) of patients RTS by three months post-operatively. Four studies including a total of 265 patients determined a pooled proportion of 96.8% (95% CI 91.0-99.7) of patients able to RTS by the 6-month post-operative stage. Pooled proportion analysis from all 11 studies comprising 659 patients showed 90.9% (95% CI 82.2-96.9) of patients were able to RTS by final follow up of 3 years.

CONCLUSION

Pooled proportion analysis showed an increasing number of patients were able to RTS after HRA over the first one year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 80% of patients were able to RTS at 6 to 12 months after HRA. The findings of this meta-analysis will enable more informed discussions between patients and healthcare professionals about time for RTS following HRA.

Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature

PURPOSE

There is currently no consensus regarding the optimal treatment for stiffness following total knee arthroplasty (TKA). With the increased utilization of value-based models, it is important to determine the most effective treatments that will reduce the need for further intervention and additional expenditure. A systematic review was performed to compare the outcomes of manipulation under anaesthesia (MUA), arthroscopic lysis of adhesions (aLOA), and revision TKA (rTKA) for arthrofibrosis and stiffness following TKA.

METHODS

PubMed and MEDLINE databases were reviewed for articles published through October 2020. Studies were included if they reported patient-reported outcome measures (PROMs) following MUA, aLOA, or rTKA. The primary endpoint was PROMs, while secondary outcomes included range of motion and the percentage of patients who pursued further treatment for stiffness.

RESULTS

A total of 40 studies were included: 21 on rTKA, 7 on aLOA, and 14 on MUA. The mean or median post-operative arc ROM was > 90° in 6/20 (30%) rTKA, 5/7 (71%) aLOA, and 7/10 (70%) MUA studies. Post-operative Knee Society (KSS) clinical and functional scores were the greatest in patients who underwent MUA and aLOA. As many as 43% of rTKA patients required further care compared to 25% of aLOA and 17% of MUA patients.

CONCLUSION

Stiffness following TKA remains a challenging condition to treat. Nonetheless, current evidence suggests that patients who undergo rTKA have poorer clinical outcomes and a greater need for further treatment compared to patients who undergo MUA or aLOA.

Epidemiology of Obese Patients Undergoing Revision Total Knee Arthroplasty: Understanding Demographics, Comorbidities, and Propensity Weighted Analysis of Inpatient Outcomes

INTRODUCTION

Obesity is a public health epidemic that is projected to grow in coming years. Observational data on the epidemiologic profile and immediate postoperative outcomes of obesity and morbid obesity after revision total knee arthroplasty (rTKA) are limited.

METHODS

Discharge data from the National Inpatient Sample was used to identify patients who underwent rTKA from 2006 to 2015. Patients were stratified into morbidly obese, obese, and not obese control cohorts. An analysis was performed to compare etiology of revision, demographic and medical comorbidity profiles, and immediate in-hospital economic and complication outcomes after rTKA.

RESULTS

An estimated 605,603 rTKAs were included in this analysis. Morbidly obese and obese patients were at significantly higher risk for any complication than not obese patients. Patients with obesity were associated with an increased risk of postoperative anemia but a lower risk of peripheral vascular disease and gastrointestinal, and hematoma/seroma complications compared with not obese patients. Patients with morbid obesity were associated with an increased risk of any, hematoma/seroma, wound dehiscence, postoperative infection, pulmonary embolism, and postoperative anemia complications and a lower risk of gastrointestinal complications when compared with not obese patients. Morbidly obese patients had a significantly longer length of stay than both obese and not obese patients, while no significant difference in length of stay was observed between obese and not obese patients.

DISCUSSION

Morbidly obese patients are at higher odds for worse postoperative medical and economic outcomes compared with those with obesity after rTKA. As the number of patients with obesity and morbid obesity continues to rise, these risk factors should be considered in preoperative discussions and perioperative protocol optimization.

A Comparison Between Unstemmed and Stemmed Constrained Condylar Knee Prostheses in Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis

Objective

To compare and analyze the clinical outcomes between unstemmed and stemmed constrained condylar knees (CCK) in complex primary total knee arthroplasty (TKA) in terms of implant survivorship, change in outcome evaluations, and complications.

Methods

We reviewed 156 consecutive patients who received primary TKA using PFC®SIGMA®TC3 (TC3) of constrained condylar design between January 2009 and January 2017 at our institution. After removing patients who met exclusion criteria, 25 patients were identified as unstemmed TC3 cases and 81 as stemmed TC3 cases. Propensity score matching was used to select 25 stemmed cases as a control group for the unstemmed group with comparable preoperative conditions including preoperative demographics, preoperative diagnosis, preoperative range of motion, main reason to use TC3, ASA score (American Society of Anesthesiologists), and follow‐up duration. Preoperative and postoperative clinical evaluations including Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, the 12‐Item Short‐Form Health Survey (SF‐12), and the range of motion (ROM) were obtained and compared. The instability, periprosthetic fracture, radiolucent lines, polyethylene wear, and heterotrophic ossification were assessed according to the anteroposterior and lateral radiographs of the knee. The complications and implant survivorship between the two groups were also recorded and compared.

Results

3After the index surgery, both groups showed substantial improvement in KSS (knee and function), HSS score, SF‐12, and ROM compared with baseline. There was no significant difference in the mean KSS scores (knee and function), HSS score, SF‐12, and ROM between the unstemmed and stemmed group postoperatively. No statistically significant difference was found in the overall complication rate between the two groups. The overall Kaplan–Meier survivorship was 98.0% (95% confidence interval 94.1%–100.0%) at 7 years. No significant difference was found in the survival rate between the unstemmed group (100.0%) and the stemmed group (96.0%) at 7 years (log rank, P = 0.317). The mean duration of follow‐up was 7.0 years for unstemmed group and 7.7 years for stemmed group.

Conclusions

In patients with adequate bone stock receiving complex primary TKA, unstemmed CCK could achieve similar clinical outcomes at mid‐term follow‐up as stemmed CCK.

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BACKGROUND

Absenteeism is costly, yet evidence suggests that presenteeism-illness-related reduced productivity at work-is costlier. We quantified employed patients' presenteeism and absenteeism before and after total joint arthroplasty (TJA).

METHODS

We measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization's Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.

RESULTS

In total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).

CONCLUSION

Among employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.

Restarting elective orthopaedic services during the COVID-19 pandemic: Do patients want to have surgery?

Aims

As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

Methods

This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery.

Results

Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03).

Conclusion

Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services.Cite this article: Bone Joint Open 2020;1-6:267-271.

Restarting elective orthopaedic services during the COVID-19 pandemic: Do patients want to have surgery?

Aims

As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

Methods

This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery.

Results

Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03).

Conclusion

Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services.

Cite this article: Bone Joint Open 2020;1-6:267–271.

Revision total knee arthroplasty versus primary total knee arthroplasty: a matched cohort study

Introduction

The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups.

Methods

Patients undergoing revision TKA for all diagnoses between 2009 and 2016 had patient-reported outcome measures (PROMs) collected prospectively. PROMs consisted of the American Knee Society Score (AKSS) and Short-Form 12 (SF-12). The study cohort was identified retrospectively and demographics were collected. The cohort was matched to a control group of patients undergoing primary TKA.

Results

Overall, 72 patients underwent revision TKA and were matched with 72 primary TKAs with a mean follow-up of 57 months (standard deviation (SD) 20 months). The only significant difference in postoperative PROMs was a worse AKSS pain score in the revision group (36 vs 44, p = 0.002); however, these patients still produced an improvement in the pain score. There was no significant difference in improvement of AKSS or SF-12 between the two groups. LOS (9.3 days vs 4.6 days) and operation time (1 hour 56 minutes vs 1 hour 7 minutes) were significantly higher in the revision group (p < 0.001). Patients undergoing revision were significantly more likely to require intraoperative lateral release and postoperative urinary catheterisation (p < 0.001).

Conclusion

This matched-cohort study provides results of revision TKA using modern techniques and implants and outlines what results patients can expect to achieve using primary TKA as a control. This should be useful to clinicians counselling patients for revision TKA.

Elective orthopaedic surgery with a designated COVID-19-free pathway results in low perioperative viral transmission rates

AIMS

The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery.

METHODS

This is a prospective study of 121 patients who underwent elective orthopaedic procedures through a COVID-free pathway. All patients underwent a 14-day period of self-isolation, had a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-free site. Baseline patient characteristics were recorded including age, American Society of Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type. Patients were contacted 14 days following discharge to determine if they had had a positive COVID-19 test (COVID-confirmed) or developed symptoms consistent with COVID-19 (COVID-19-presumed).

RESULTS

The study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years ± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70 patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19 test in the postoperative period. One patient (0.8%) developed anosmia postoperatively without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and self-isolated for seven days. Her symptoms resolved within a few days.

CONCLUSION

The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. While both surgeons and patients should remain vigilant, elective surgery can be safely restarted using dedicated pathways and procedures.Cite this article: Bone Joint Open 2020;1-9:562-567.

Effect of knee arthroplasty on sports participation and activity levels: a systematic review and meta-analysis

Objective

Desires and expectations of patients in regard to resume participation in sport activities after knee arthroplasty strongly increased in recent years. Therefore, this review systematically reviewed the available scientific literature on the effect of knee arthroplasty on sports participation and activity levels.

Design

Systematic review and meta-analysis.

Data sources

PubMed, Embase, SPORTDiscus and reference lists were searched in February 2019.

Studies eligibility criteria

Inclusion of knee osteoarthritis patients who underwent total knee arthroplasty (TKA) and/or unicondylar knee arthroplasty. Studies had to include at least one preoperative and one postoperative measure (≥1 year post surgery) of an outcome variable of interest (ie, activity level: University of California, Los Angeles and/or Lower Extremity Activity Scale; sport participation: type of sport activity survey).

Results

Nineteen studies were included, consisting data from 4074 patients. Knee arthroplasty has in general a positive effect on activity level and sport participation. Most patients who have stopped participating in sport activities in the year prior to surgery, however, do not seem to reinitiate their sport activities after surgery, in particular after a TKA. In contrast, patients who continue to participate in sport activities until surgery appear to become even more active in low-impact and medium-impact sports than before the onset of restricting symptoms.

Conclusions

Knee arthroplasty is an effective treatment in resuming sports participation and physical activity levels. However, to achieve the full benefits from knee arthroplasty, strategies and guidelines aimed to keep patients capable and motivated to participate in (low-impact or medium-impact) sport activities until close before surgery are warranted.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030

BACKGROUND

As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA.

METHODS

The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age.

RESULTS

In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA.

CONCLUSION

The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends.

LEVEL OF EVIDENCE

IV.

Therapeutic exercise and radiofrequency in the rehabilitation project for hip osteoarthritis pain

BACKGROUND

Severe hip osteoarthritis is responsible for disabling pain and functional impairment of the joint. Although total hip arthroplasty (THA) is a successful treatment, some patients have multiple comorbidities that represent contraindications for THA. Conventional drug therapies are often ineffective or responsible for numerous side effects. For these patients, it is difficult to draw up an acceptable rehabilitation path, as the main limitation is intense pain. New rehabilitation strategies that relieve pain and improve articular function need to be developed. The combination of traditional treatments such as education and therapeutic exercise with innovative, minimally-invasive therapies such as continuous radiofrequency (CRF) appears to reduce hip pain by determining the neurolysis of the joint.

AIM

The aim of our study was to describe the reduction in pain and improvements in joint function when CRF is combined with the therapeutic exercise in rehabilitation of patients with severe hip osteoarthritis.

DESIGN

Case series study.

SETTING

Rehabilitation service outpatients.

POPULATION

Twenty-five patients with severe hip osteoarthritis causing disabling pain and with contraindications to THA, and for whom conventional drug therapies were ineffective or responsible for numerous side effects.

METHODS

The study design included: initial clinical-functional assessment using the Harris Hip Score (HHS), the Numeric Rating Scale (NRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); a pre-lesion anaesthetic block; hip neuroablation with CRF; a three-week kinesitherapy protocol (3 sessions per week); two further assessments using the same scales one month (T1) and six months (T2) after CRF.

RESULTS

Improvements at T1 and T2 follow-ups, after CRF (P=0.000) were recorded for articular pain and function. However, results at T2 were worse than those at T1 (P=0.000).

CONCLUSIONS

CRF combined with therapeutic exercise in rehabilitation of severe hip osteoarthritis is an attractive option for significant pain relief as it allows patients to carry out kinesitherapy more easily.

CLINICAL REHABILITATION IMPACT

CRF could represent a valid alternative in the rehabilitation of patients with severe hip osteoarthritis especially when other therapeutic approaches are unworkable.

Association between patient survival following reoperation after total hip replacement and the reason for reoperation: an analysis of 9,926 patients in the Swedish Hip Arthroplasty Register

Background and purpose - The association between long-term patient survival and elective primary total hip replacement (THR) has been described extensively. The long-term survival following reoperation of THR is less well understood. We investigated the relative survival of patients undergoing reoperation following elective THR and explored an association between the indication for the reoperation and relative survival. Patients and methods - In this observational cohort study we selected the patients who received an elective primary THR and subsequent reoperations during 1999-2017 as recorded in the Swedish Hip Arthroplasty Register. The selected cohort was followed until the end of the study period, censoring or death. The indications for 1st- and eventual 2nd-time reoperations were analyzed and the relative survival ratio of the observed survival and the expected survival was determined. Results - There were 9,926 1st-time reoperations and of these 2,558 underwent further reoperations. At 5 years after the latest reoperation, relative survival following 1st-time reoperations was 0.94% (95% CI 0.93-0.96) and 0.90% (CI 0.87-0.92) following 2nd-time reoperations. At 5 years patients with a 1st-time reoperation for aseptic loosening had higher survival than expected; however, reoperations performed for periprosthetic fracture, dislocation, and infection had lower survival. Interpretation - The relative survival following 1st- and 2nd-time reoperations in elective THR patients differs by reason for reoperation. The impact of reoperation on life expectancy is more obvious for infection/dislocation and periprosthetic fracture.