Fast-track surgery for bilateral total knee replacement

Simultaneous bilateral TKA in the context of fast track surgery - Do patients meet discharge criteria as anticipated?

BACKGROUND

The efficacy and safety of enhanced recovery after surgery (ERAS) protocols for patients undergoing total knee arthroplasty (TKA) have been generally proven. Previous studies investigating patients undergoing simultaneous bilateral TKA (SBTKA) focused on complications, mortality, and pain and did not examine patients' functional limitations. Therefore, the aim of this study was to investigate to what extent patients undergoing SBTKA are able to meet functional discharge criteria originally designed for their counterparts undergoing unilateral TKA (UTKA) in an ERAS setting.

MATERIALS AND METHODS

All patients who received primary SBTKA between June 2015 and December 2018 were included in this retrospective analysis. For comparison, UTKA patients were matched 1:1 to SBTKA patients using Propensity Score Matching based on age, gender, and BMI. The times to achieving the rehabilitation checkpoints of walking 150 m, walking a flight of stairs, and 90° knee flexion were evaluated.

RESULTS

63 (SBTKA group) and 64 (UTKA group) patients were included. Due to the Propensity-Score-Matching there were no differences regarding age, gender, and BMI. The mean length of stay (LOS) was 9.1 days in the SBTKA and 7.6 days in the UTKA group (p = 0.003). On average, it took SBTKA patients 5.4 days to achieve an uninterrupted walking distance of at least 150 m, while it took UTKA patients 4.1 days (p < 0.001). Mean time to walking a flight of stairs was 6.3 days for SBTKA patients and 4.7 days for UTKA patients (p < 0.001). 90° flexion was achieved after 4.1 days by SBTKA patients and 3.5 days by UTKA patients (p = 0.241).

CONCLUSION

The vast majority of SBTKA patients were able to achieve functional discharge criteria within their inpatient stay when allowed about 30% extra time. Therefore, functional discharge criteria in ERAS protocols designed for UTKA can be considered appropriate for SBTKA patients.

LEVEL OF EVIDENCE

Therapeutic Level III.

A new dressing system for accelerating wound recovery after primary total knee arthroplasty: a feasibility study

PURPOSE

Currently, postoperative wound infection and poor healing of total knee arthroplasty have been perplexing both doctors and patients. We hereby innovatively invented a new dressing system to reduce the incidence of postoperative wound complications.

METHODS

We enrolled 100 patients who received primary unilateral total knee arthroplasty and then applied the new dressing system. The data collected included the number of dressing changes, postoperative hospital stay, Visual Analogue Scale score (VAS), the Knee Society Score (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), ASEPSIS scores, The Stony Brook Scar Evaluation Scale (SBSES), wound complications, dressing cost, the frequency of shower and satisfaction. Subsequently, a statistical analysis of the data was performed.

RESULTS

Our findings demonstrated the average number of postoperative dressing changes was 1.09 ± 0.38, and the average postoperative hospital stay was 3.72 ± 0.98 days. The average cost throughout a treatment cycle was 68.97 ± 12.54 US dollars. Collectively, the results of VAS, KSS, and KOOS revealed that the pain and function of patients were continuously improved. The results of the four indexes of the ASEPSIS score were 0, whereas the SBSES score was 3.58 ± 0.52 and 4.69 ± 0.46 at two weeks and one month after the operation, respectively. We observed no wound complications until one month after the operation. Remarkably, the satisfaction rate of the patients was 91.85 ± 4.99% one month after the operation.

CONCLUSION

In this study, we invented a new dressing system for surgical wounds after total knee arthroplasty and further confirmed its clinical feasibility and safety.

CHINESE CLINICAL TRIAL REGISTRY

ChiCTR2000033814, Registered 13/ June/2020.

Complications following single-stage bilateral total knee arthroplasty and unilateral procedures: experience of a high-volume community hospital

INTRODUCTION

The safety of single-stage bilateral total knee arthroplasty (SSBTKA) compared to unilateral total knee arthroplasty (TKA) remains controversial. The present study compares the 90-day postoperative complications encountered following SSBTKA and unilateral TKA in an unselected cohort of patients performed at a high-volume community hospital.

MATERIALS AND METHODS

The perioperative electronic medical records of an unselected consecutive cohort of 1032 patients (1345 knees) having undergone unilateral or SSBTKA were reviewed. Ninety-day postoperative complications or need for additional procedures were compared between unilateral and SSBTKA groups.

RESULTS

A total of 719 and 313 patients underwent unilateral and SSBTKA, respectively. There were no significant differences in age or BMI between groups. Patients undergoing SSBTKA were more likely to be male (p = 0.019), have longer lengths of stay (p < 0.001) and were less likely to discharge directly home (13.1%) compared to unilateral patients (80.9%) (p < 0.001). Patients undergoing SSBTKA were more likely to require a transfusion (14.7%) compared to unilateral patients (2.2%) (p < 0.001). Interestingly, mortality rate following unilateral TKA (1.7%) was significantly higher than SSBTKA (0.0%) (p = 0.013). There were no significant differences regarding other complications or need for additional procedures within 90 days following surgery.

CONCLUSION

SSBTKA did not result in greater complications when compared to unilateral TKA in this particular cohort. As expected, transfusion rates will likely be higher and there will be a greater need for acute inpatient care following surgery for SSBTKA patients.

A New Dressing System for Wound in Enhanced-Recovery Total Hip Arthroplasty: A Randomized and Controlled Trial

BACKGROUND

Currently, there is a paucity of recommendations in regards to dressing selection within the enhanced recovery after surgery protocol. We devised a new dressing system to accelerate the recovery after total hip arthroplasty (THA). We aimed to present our experience with this new dressing system as an adjunct to wound management in THA and to evaluate its performance.

METHODS

From September 2020 to August 2021, we prospectively enrolled 124 patients who underwent a primary THA. The patients were randomly assigned to the intervention (the new dressing system group) or the control (the traditional gauze dressing) group. The primary outcome measures of this study were numbers of dressing changes, postoperative lengths of stay, wound scores including the Stony Brook Scar Evaluation Scale and ASEPSIS scores and wound-related complications. The secondary outcomes include satisfaction scores, dressing-related costs, and pain and functional recovery scores.

RESULTS

The intervention group numbers of dressing changes and postoperative lengths of stay were significantly less than the control group (P < .001, P < .001). During the one-month follow-up, the Stony Brook Scar Evaluation Scale in the intervention group was significantly better than that in the control group (P < .001). The intervention group satisfaction was significantly higher than that in the control group (P < .001). There were no statistically significant differences between the two groups in terms of dressing-related costs and pain and function scores.

CONCLUSION

The new dressing system could significantly reduce the number of dressing changes and postoperative lengths of stay and increase patient satisfaction scores, which can be an ideal adjunct to wound management in enhanced-recovery THA.

Bilateral Total Knee Arthroplasty: Current Concepts Review

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Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days.

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Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others.

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While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA.

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When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart.

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Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Blood Transfusion can be Avoided in Single-Anesthetic Bilateral Total Knee Arthroplasty

BACKGROUND

Female gender and surgical drain use have been associated with an increased transfusion risk following single-anesthetic bilateral total knee arthroplasty (SBTKA). This study evaluated allogenic blood transfusion rates among female and male patients undergoing SBTKA with intraoperative tourniquet, tranexamic acid and contemporary blood transfusion thresholds but without surgical drain use.

METHODS

We performed a retrospective electronic medical record review for 125 consecutive patients undergoing SBTKA (250 knees) between May 1, 2015 and July 10, 2021. Patient demographic characteristics (age, gender, body mass index, American Society of Anesthesiologists), preoperative and postoperative hemoglobin levels, perioperative transfusions, operative time, and hospital length of stay were compared between 76 female (60.8%) and 49 male (39.2%) patient cohorts using paired Student's t-test or Fisher's exact test with a P value <.05 for significance.

RESULTS

No patient in either gender-based cohort received a perioperative allogeneic or autologous blood transfusion (P = 1). There were no significant differences in patient demographic features or medical comorbidities. Male patients had significantly higher mean preoperative (14.7 versus 13.7 g/dL, P < .01) and postoperative (12.7 versus 11.8 g/dL, P < .01) hemoglobin levels and a shorter mean hospital length of stay (2.5 versus 3.0 days, P < .01). There was no difference in the mean operative time (154.7 versus 150.7 minutes, P = .34) or change in the hemoglobin level (2.1 versus 1.9 g/dL, P = .27).

CONCLUSION

SBTKA can be performed with a limited risk of perioperative transfusion with a combination of intraoperative tourniquet, tranexamic acid, conservative blood transfusion criteria, and avoidance of postoperative drain use. Study results were not influenced by patient gender.

LEVEL OF EVIDENCE

This is a level III, retrospective cohort study.

A waterproof, low-cost dressing system reduces postoperative wound dressing changes in primary total hip arthroplasty: An efficacy study

Backgrounds

Postoperative wound complication is a major risk factor for the development of Periprosthetic joint infection. We innovatively invented a new dressing system to reduce the occurrence of postoperative wound complications and improve the quality of life of patients after total hip arthroplasty.

Methods

A total of 120 patients who underwent primary unilateral total hip arthroplasty were enrolled in this study. The data collected included the number of dressing changes, costs of the dressings, postoperative hospital stay, The Visual Analogue Scale (VAS) score, The Harris Hip Score (HHS), ASEPSIS score, The Stony Brook Scar Evaluation Scale (SBSES), wound complications, the frequency of showers and satisfaction. Data were statistically analyzed.

Results

The average number of dressing changes was 0.74 ± 0.46, while the average postoperative hospital stay was 3.67 ± 0.97 days. The average cost of the new dressings throughout a treatment cycle was 57.42 ± 15.18 dollars. The VAS score decreased from 5.63 ± 1.09 before the operation to 0.88 ± 0.54 one month after the operation. The HHS score increased from 70.18 ± 7.84 before the operation to 80.36 ± 4.08 one month after the operation. The results of the four indexes of the ASEPSIS score were all 0. The SBSES score was 3.55 ± 0.61 at two weeks after the operation, and 4.38 ± 0.71 at one month after the operation. No wound complications were recorded until one month after the operation when the satisfaction rate was 92.53 ± 3.62%.

Conclusion

In this study, we have invented a new dressing system for surgical wounds after total hip arthroplasty and confirmed its efficacy.

Chinese Clinical Trial Registry

ChiCTR2000033822, Registered 13/ June/2020

A New Dressing System Reduces the Number of Dressing Changes in the Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Purpose

We devised a novel dressing system to accelerate the recovery after total knee arthroplasty (TKA). The purpose of this study was to assess the clinical outcomes and economic expenses of the new dressing system.

Methods

In this randomized and controlled trial, we enrolled 98 patients who underwent the first unilateral TKA between September 2020 and June 2021. The patients were randomly assigned to one of two groups: the intervention (the new dressing system group) or the control (the traditional gauze dressing) group. We gathered and evaluated patient data including age, gender, body mass index, surgical side, number of dressing changes, post-operative hospital stay, dressing-related expense, satisfaction, pain and function scores, wound scores and wound-related complications.

Results

The number of dressing changes and post-operative hospital stay in the intervention group were significantly less than in the control group (p = 0.000, p = 0.002). Satisfaction in the intervention group was significantly higher than in the control group's (p = 0.000). There were no significant differences between the two groups in dressing-related expense, pain and function scores. During the one month follow-up, the intervention group's Stony Brook Scar Evaluation Scale (SBSES) was considerably higher than the control group's (p = 0.012).

Conclusion

The new dressing system can reduce the number of dressing changes and post-operative hospital stays while increasing patient satisfaction with no difference in medical costs in TKA. This wound dressing system has potential for application in TKA.

Clinical Trial Registration

https://clinicaltrials.gov, identifier ChiCTR2000033814.

Staging Bilateral Total Knee Arthroplasties Reduces Alignment Outliers

BACKGROUND

Patients frequently present with bilateral symptomatic knee osteoarthritis and request simultaneous total knee arthroplasties (TKAs). Technical differences between simultaneous and staged TKAs could affect clinical and radiographic outcomes. We hypothesized that staged TKAs would have fewer mechanical alignment outliers than simultaneous TKAs.

METHODS

We reviewed 87 simultaneous and 72 staged TKAs with at least 2 years of follow-up. Radiographic assessment was done using standing long leg and lateral radiographs of the knee. Coronal and sagittal measurements were performed by 4 blinded observers on 2 separate occasions with an intraobserver agreement of 0.95 and interobserver of 0.92.

RESULTS

The first simultaneous knee had no difference in the probability of establishing the mechanical axis outside 3° of neutral (45%) compared to the first staged knee (54%, P = .337). However, the second simultaneous knee (49%) was more likely to establish the axis outside mechanical neutral compared to the second staged knee (28%; odds ratio 2.54, confidence interval 1.31-4.94, P = .006). There was an increased risk of deep venous thrombosis with staged TKA (odds ratio 2.96, confidence interval 1.28-6.84, P = .011), but other perioperative complication rates were not significantly different. There were no clinically significant differences in range of motion or Knee Society Score.

CONCLUSION

There is a significantly increased risk of establishing the second knee outside mechanical neutral during a simultaneous TKA compared to staged bilateral TKAs, possibly related to a number of surgeon-related and system-related factors. The impact on clinical outcomes and radiographic loosening may become significant in long-term follow-up.

The Safety of Bilateral Simultaneous Hip and Knee Arthroplasty versus Staged Arthroplasty in a High-Volume Center Comparing Blood Loss, Peri- and Postoperative Complications, and Early Functional Outcome

Purpose: In recent years, there has been increasing interest in the use of simultaneous hip and knee arthroplasty compared to staged procedures in patients with bilateral pathology. The aim of this study was to compare simultaneous and staged hip and knee arthroplasty in patients with bilateral pathology by assessing the transfusion rate, postoperative hemoglobin drop, length of stay (LOS), in-hospital complications, 30-day readmissions and early functional outcome. Methods: We conducted a retrospective cohort study that included all patients who were undergoing primary TKA, THA and UKA by a single surgeon in a high-volume arthroplasty center between 2015 and 2020 as simultaneous or staged procedures. Staged bilateral arthroplasties were performed within 12 months and were stratified by the time between procedures. Data were acquired through the electronic files at the Orthopädische Chirurgie München (OCM). For functional outcome, the ability of the patients to walk independently on the ward was compared with the ability to walk a set of stairs alone, which was recorded daily by the attending physiotherapist. Results: In total n = 305 patients were assessed for eligibility and included in this study. One hundred and forty-five patients were allocated to the staged arthroplasty group. This group was subdivided into a hip and a knee group, whereas the knee group was split into TKA and UKA. The second staged procedure was performed within 12 months of the first procedure. One hundred and sixty patients were allocated to the simultaneous arthroplasty group. This group was also subdivided into a hip and knee group, whereas the knee group was split again into a TKA and UKA group. No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: There was no significant difference in the transfusion rate or complication rate. Secondarily, no statistically significant difference was found between the postoperative hemoglobin drop and the functional outcome, or in the length of stay (LOS) between both groups. Walking the stairs showed a significant difference in the knee group. Conclusions: There were no significant differences observed in the transfusion rate in-hospital complications, or readmission rate between both groups. The early functional outcome showed no significant difference in mobility for all groups. Simultaneous arthroplasty for knee or hip is as safe as a staged procedure, with no higher risk for the patient, in a specialized high-volume center. Level of evidence: Level IV.

Interval Between Staged Bilateral Total Knee Arthroplasties Does Not Affect Early Medical or Surgical Complications

BACKGROUND

The purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications.

METHODS

A retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome.

RESULTS

The mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration.

CONCLUSION

The interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery.

Rapid rehabilitation nursing improves clinical outcomes in postoperative patients with colorectal carcinoma: A protocol for randomized controlled trial

BACKGROUND

Colorectal carcinoma has a high incidence rate and the high mortality rate has always been an important global health challenge. Surgical treatment is widely performed in patients with colorectal carcinoma. Fast track surgery (FTS) applies evidence-based medical concept to optimize the management during the operation, so as to reduce the psychological and physical trauma stress of surgical patients and make them recover rapidly. We perform this protocol for randomized controlled study to evaluate the efficacy of a rapid rehabilitation care in colorectal carcinoma surgery.

METHODS

It is a single-center randomized controlled study to be conducted from January 2021 to December 2021. It was authorized via the Ethics Committee of the Huzhou Central Hospital (20191127-01). Eighty participants who undergo colorectal carcinoma surgery will be included in this research. Patients are randomly assigned to control group (standard management group, including 40 samples) and study group (the FTS group, including 40 samples). The main results are times of postoperative exhaust, first defecation, ambulation, first eating, and postoperative hospital stay. Secondary outcomes are incidence of nausea and emesis, wound infection, urinary tract infection, lung infection, deep vein thrombosis, and rehospitalization rate among the 2 groups. All analyses are conducted using the SPSS for Windows Release 15.0.

RESULTS

Figure 1 shows the clinical results between groups.

CONCLUSION

The research can offer a reliable basis for the effectiveness of a rapid recovery nursing program in patients with colorectal carcinoma.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6038).

Return to Work After Total Joint Arthroplasty: A Predictive Model

Returning to work after surgery is a primary concern of patients who are contemplating total joint arthroplasty (TJA). The ability to return to work has enormous influence on the patient's independence, financial well-being, and daily activities. The goal of this study was to determine the independent patient variables that predict return to work as well as to create a predictive model. From June 2017 to December 2017, a total of 391 patients who underwent primary TJA (243 hips, 148 knees) were prospectively enrolled in the study to obtain information on return to work after surgery. Patients were sent a series of questions in a biweekly survey. Information was collected on the physical demands of their occupation, the number of hours spent standing, the limitations to return to work, and the use of assistive devices. Bivariate analysis was performed, and a multiple linear regression model was created. Most (89.6%) patients returned to work within 12 weeks of surgery. Patients who underwent total hip arthroplasty returned to work earlier than those who underwent total knee arthroplasty (5.56 vs 7.79 weeks, respectively). Analysis showed the following independent predictors for faster return to work: self-employment, availability of light-duty work, male sex, and higher income. Predictors for slower return to work included a physically demanding occupation (at least 50% physical duties), knee arthroplasty, longer length of stay, and a job requiring more hours spent standing. This model reported an adjusted R² of 0.332. The findings provide an objective predictive model of the patient- and procedure-specific characteristics that affect postoperative return to work. Surgeons should consider these factors when counseling patients on their postoperative expectations. [Orthopedics. 2020;43(5):e415-e420.].

Simultaneous single-stage versus two-staged bilateral total knee arthroplasty: a prospective comparative study

PURPOSE

The study aims to prospectively compare peri-operative morbidity and mortality of simultaneous single-stage bilateral total knee arthroplasty (SS BLTKA) with two-staged bilateral total knee arthroplasty (TS BLTKA) performed within 12 months of the first surgery. We hypothesized that SS BLTKA is as safe as TS BLTKA.

METHODS

Patients with a minimum follow-up of 12 months were included in this study. Oxford knee score and quality of life index SF12 was compared between the 2 groups at six weeks and six month follow-up.

RESULTS

SS BLTKA included 250 patients and TS BLTKA included 210 patients. The minimum time interval between two operations was three weeks (mean 1.6 months, range 3 weeks-12 months). There was no significant difference between the 2 groups in peri-operative mortality, surgical site infection, major peri-operative complications. There was no difference between the 2 groups in the Oxford knee score and quality of life index SF12 at 6-month follow-up. There was no difference in the range of knee flexion between the 2 groups at six months. Post-operative haemoglobin drop was significantly more in SS BLTKA patients and consequently, blood transfusion requirement was significantly higher in SS BLTKA. There was a significantly higher length of hospital stay and duration of surgery in TS BLTKA group.

CONCLUSION

There does not appear to be a difference in complication rates between the 2 groups. SS BLTKA seems to be a logical choice if both knees have severe osteoarthritis. Patients with severe cardiopulmonary compromise were excluded, and a unilateral procedure may be preferred in them.

Patients return to work sooner after unicompartmental knee arthroplasty than after total knee arthroplasty

PURPOSE

It is not yet known if unicompartmental knee arthroplasty (UKA) patients are more likely to return to work sooner or have improved ability to work (i.e., workability) than total knee arthroplasty (TKA) patients. The following questions were addressed: patients were assessed to determine: (1) whether they returned to work sooner following UKA compared to TKA; (2) whether UKA patients had better WORQ function scores compared to TKA patients; and (3) if UKA patients have higher workability scores and greater satisfaction regarding workability than TKA patients.

METHODS

A multicenter retrospective cohort study was performed that included patients at least 2 years after having undergone either UKA or TKA surgery and on the condition that patients had been in work in the 2 years prior to surgery. Time period between stopping work and returning to work was assessed; the WORQ scores (0 = worst-100 = best) and the Work Ability Index (WAI = 0-10) and reported satisfaction with work ability.

RESULTS

UKA patients (n = 157, median 60 years, 51% male) were compared to TKA patients (n = 167, median 60 years, 49% male) (n.s.). Of the 157 UKA patients, 115 (73%) returned to work within 2 years compared to 121 (72%) of TKA patients (n.s.). More UKA patients return to work within 3 months (73% versus 48%) (p < 0.01). WORQ scores improved similarly in both groups. The WAI was also comparable between the groups. Dissatisfaction with workability was comparable (UKA 15% versus TKA 18% (n.s.).

CONCLUSION

TKA and UKA patients have similar WORQ, WAI, and satisfaction scores. However, in this study population, UKA patients to return to work after surgery significantly sooner than TKA patients, which improves their quality of life and allows them to participate actively in society. This information can help health care providers and patients weigh-up the pros and cons and choose the best treatment and timing for patients in the working population.

LEVEL OF EVIDENCE

III.

Clinical information and guidance shared via a patient infotainment system can reduce hospital stay and maintain 2 medical quality for total knee arthroplasty: A single-blinded quasi-randomised controlled trial

BACKGROUND

The demand for total knee arthroplasty is increasing worldwide. Optimising results and meeting patients' expectations are more challenging than before, because the length of hospitalisation has markedly reduced and the standard care processes have been accelerated. We incorporated an interactive patient infotainment system into the standard clinical pathway for total knee arthroplasty in the hope of improving patients' length of stay.

OBJECTIVES

To analyse whether incorporation of an interactive infotainment system reduced the length of stay and improved the quality of medical care (in terms of number of medical orders and emergency room returns).

DESIGN

A prospective, quasi-randomised controlled trial.

PARTICIPANTS AND SETTING

Data of 86 patients hospitalised for a unilateral total knee arthroplasty at a medical centre in Taiwan were analysed.

METHODS

From January 2017 to July 2017, 86 patients who underwent unilateral total knee arthroplasty and were cared for under a standard clinical pathway were included. The study group (41 patients) had access to electronic programs and video demonstrations related to health literacy, physical therapy, home care and precautions following total knee arthroplasty via a patient infotainment system, while the control group (45 patients) did not. Hospital course, quality indices, in-hospital medical costs, returns to the emergency room and readmission at 30 or 90 days were analysed and compared between the two groups of patients.

RESULTS

The study group had a shorter length of stay (4.4 vs. 4.8 days, mean differences [MD] = -0.37, 95% CI -0.71 to -0.03, p = 0.026) and fewer medical orders (109 vs 111 orders, MD = -1.86, 95% confidence intervals (CI) -3.58 to -0.15, p = 0.047) as compared with the control group. The incidences of emergency room return and readmission to the hospital at 30 or 90 days were comparable between the two groups. No difference in the total medical cost was found between the two groups, with only the cost of laboratory tests in the study group being significantly lower than that in the control group ($144 vs. $163, MD = -21.7, 95% CI -41.0 to -2.25, p = 0.007).

CONCLUSIONS

The incorporation of a patient infotainment system into the standard clinical pathway for total knee arthroplasty can efficiently reduce the length of hospital stay and maintain the quality of medical care. Further studies on improvement of patient medical literacy with the help of the infotainment system would be of interest in order to improve clinical practice and patient satisfaction.

REGISTRATION NUMBER

NCT03788798 TWEETABLE ABSTRACT: A patient infotainment system can reduce hospital stay and maintain medical quality for total knee arthroplasty.

Simultaneous vs staged bilateral total knee arthroplasty: a propensity-matched case-control study from nine fast-track centres

INTRODUCTION

Limited data exist on patient safety after simultaneous vs staged bilateral total knee arthroplasty (TKA) in matched groups. Hence, the aim of this study was to compare length of stay (LOS), in-hospital complications, 30-day readmissions and mortality after simultaneous and staged bilateral TKA in matched patients.

PATIENTS AND METHODS

A retrospective case-control study of prospectively collected data in nine centres from February 2010 to November 2015. Propensity scores (PS) were used to match simultaneous and staged (1-6 months between stages) bilateral TKA patients with prospectively collected patient characteristics from the Lundbeck Foundation Centre for Fast-track THA and TKA Database. 30-day follow-up was acquired from the Danish Patient Registry and patient records.

RESULTS

A total of 344 (47.1%) simultaneous and 386 (52.9%) staged bilateral TKA procedures were performed. PS matching was possible in 232 simultaneous and 232 staged bilateral TKA patients. LOS was median 4 days (IQR 3-5) after simultaneous and cumulated 4 days (IQR 4-6) after staged procedures. The in-hospital complication rate was 15.5% after simultaneous vs 7.3% (p = 0.004) after staged procedures. Two cases (0.9%) of venous thromboembolic events were found in each group. Eight patients (3.4%) were re-operated after simultaneous vs one patient (0.4%) after staged bilateral TKA (p = 0.037). The 30-day readmission rate was 8.6% after simultaneous vs 5.6% after staged procedures (p = 0.281). No patients died in either group.

CONCLUSIONS

We found no significant differences in 30-day readmission rates and mortality between simultaneous and staged bilateral TKA, but the in-hospital complication rate and re-operation rate was higher after the simultaneous procedure calling for further matched investigations in larger cohorts.

Outpatient total knee arthroplasty: Readmission and complication rates on day 30 in 61 patients

BACKGROUND

Total knee arthroplasty (TKA) on an outpatient basis is controversial due to concerns about patient safety. In France, only 1.1% of TKAs performed in 2017 were outpatient procedures. Nevertheless, recent advances in the multi-modal and multidisciplinary management of TKA patients combined with optimisation of the various components of perioperative care are increasing the use of outpatient TKA. However, studies on outcomes remain scarce. The primary objective of this work was to compare readmission rates within 30 days after TKA between patients managed as outpatients and as inpatients. The secondary objectives were to compare complication rates and patient satisfaction between the two groups.

HYPOTHESIS

After outpatient TKA, the day-30 rates of readmission and complications are similar to those seen after inpatient TKA.

MATERIAL AND METHODS

A retrospective single-centre study of consecutive patients who underwent TKA between April 2014 and July 2017 was performed. Readmissions, complications, and patient satisfaction were collected.

RESULTS

Of 574 patients, 61 were selected to undergo outpatient TKA and 513 had inpatient TKA. The day-30 readmission rate was 2/61 (3.3%) in the outpatient group and 25/513 (4.9%) in the inpatient group. The overall complication rate was 8% in the outpatients and 7.2% in the inpatients. The satisfaction rate was high in the outpatient group, with 80% very satisfied and 20% satisfied patients.

CONCLUSION

When performed in appropriately selected patients, outpatient TKA is not associated with a higher readmission rate compared to inpatient TKA.

LEVEL OF EVIDENCE

IV, retrospective comparative study.

Simultaneous, same-anaesthetic bilateral total knee arthroplasty has low mortality and complication rates

PURPOSE

The benefits of simultaneous bilateral total knee arthroplasty (SBTKR) include reduced hospital costs, single anaesthetic exposure and in many cases is also the patient's preference. Despite these potential benefits, risk-adversity with respect to assumed complications and mortality make it difficult for the orthopaedic surgeon and patient to make an informed decision. This study aimed to address the inconsistencies and lack of consensus in previous literature regarding the short-term complications and clinical safety of SBTKR in patients with end-stage knee osteoarthritis (OA).

METHODS

A cohort of 950 knees (475 patients) undergoing surgery between 2008 and 2013 was extracted from a prospectively collected clinical database and retrospectively linked to the Australian Joint Replacement Registry and hospital records. Patients underwent sequential SBTKR by their treating surgeon under one anaesthetic. Basic demographic data and outcome data including complications and mortality were collected. All data were analyzed using descriptive statistics only.

RESULTS

A total of 413 patients and 826 knees were included. The average age of the cohort was 70 years with range between 46 and 88 years. 50% of patients were female. The overall mortality rate during the study follow-up period was 1.9%, with an average time to death postoperatively of 23.8 months. There were no cases of acute postoperative mortality (< 6 weeks). Medical complication rates were low.

CONCLUSIONS

In contrast to the higher mortality and complication rates suggested in previous literature, this study has demonstrated that SBTKR is safe, with low mortality and complication rates under the current surgical protocol.

LEVEL OF EVIDENCE

IV.

Optimizing Intraoperative Blood Management for One-Stage Bilateral Total Knee Arthroplasty

BACKGROUND

Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions?

METHODS

We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence.

RESULTS

A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation.

CONCLUSION

Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines.

Modified protocol for enhanced recovery after surgery is beneficial for Chinese cancer patients undergoing pancreaticoduodenectomy

Radical surgical resection remains the only effective treatment for advanced pancreatic cancer. Effective protocols for recovery from post-operative complications that result in high rates of morbidity and mortality are therefore essential. The enhanced recovery after surgery (ERAS) protocol is an interdisciplinary multimodal concept based on modern anesthesia and analgesia combined with other fast rehabilitation parameters. It was first applied in the field of elective colorectal surgery, and eventually extended to several surgical diseases. In this study, we investigated the feasibility and safety of implementing the ERAS protocol in patients undergoing pancreaticoduodenectomy (PD). We randomly divided 159 patients who underwent PD into two groups who were managed using either ERAS or the conventional protocol. We observed that in those treated with the ERAS protocol several post-operative recovery factors were greatly improved, and there were no complications requiring readmission. We therefore propose that ERAS can improve post-operative recovery of PD patients and shorten the waiting time to chemotherapy, which may improve the overall survival of surgically treated pancreatic cancer patients.

Fast-tracking for total knee replacement reduces use of institutional care without compromising quality

Background and purpose - Fast-tracking shortens the length of the primary treatment period (length of stay, LOS) after total knee replacement (TKR). We evaluated the influence of the fast-track concept on the length of uninterrupted institutional care (LUIC) and other outcomes after TKR. Patients and methods - 4,256 TKRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast track (Hospital A) and non-fast track (Hospitals B, C and D). We analyzed length of uninterrupted institutional care (LUIC), LOS, discharge destination, readmission, revision, manipulation under anesthesia (MUA) and mortality rate in each hospital. We compared these outcomes for TKRs performed in Hospital A before and after fast-track implementation and we also compared Hospital A outcomes with the corresponding outcomes for the other 3 hospitals. Results - After fast-track implementation, median LOS in Hospital A fell from 5 to 3 days (p < 0.001) and (median) LUIC from 7 to 3 (p < 0.001) days. These reductions in LOS and LUIC were accompanied by an increase in the discharge rate to home (p = 0.01). Fast-tracking in Hospital A led to no increase in 14- and 42-day readmissions, MUA, revision or mortality compared with the rates before fast-tracking, or with those in the other hospitals. Of the 4 hospitals, LOS and LUIC were most reduced in Hospital A. Interpretation - A fast-track protocol reduces LUIC and LOS after TKR without increasing readmission, complication or revision rates.

Ninety-Day Morbidity and Mortality in Risk-Screened and Optimized Patients Undergoing Two-Team Fast-Track Simultaneous Bilateral TKA Compared With Unilateral TKA-A Prospective Study

BACKGROUND

Simultaneous bilateral total knee arthroplasty (SBTKA) offers significant socioeconomic benefits. However, retrospective studies and public health data show increased mortality and morbidity rates in patients undergoing SBTKA compared with those undergoing unilateral TKA (UTKA), and there have been recommendations against the use of SBTKA. High-volume centers, which feature careful patient selection and fast-tracked surgery, continue to perform SBTKA and have published their results in favor of the procedure. However, the quality of evidence remains poor.

METHODS

We prospectively examined 90-day morbidity and mortality of SBTKA compared with UTKA in risk-screened and optimized patients in our high-volume joint replacement facility. A total of 1200 consecutive patients were recruited in each arm.

RESULTS

Ninety-day mortality was higher in SBTKA patients than in UTKA patients (0.58% vs 0.42%, respectively; P = .5646). Overall procedure-related complications were significantly higher in the SBTKA group (7.25% vs 4.42%, respectively; P = .0034). The relative risk of cardiovascular complications in SBTKA patients was 6.5 times higher than that in UTKA patients (1.08% vs 0.17%, respectively; P = .0136). Neurological complications were 9.5 times more common in the SBTKA group (1.58% vs 0.17%, respectively; P = .0024). All other complications were comparable in the 2 groups.

CONCLUSION

Risk screening and preoperative optimization reduce mortality and overall complication rates in SBTKA patients; however, overall procedure-related complications, specifically cardiovascular and neurological, remain significantly high in SBTKA patients, for which a guarded approach is recommended.

Does blood transfusion type affect complication and length of stay following same-day bilateral total knee arthroplasty?

Same-day Bilateral Total Knee Arthroplasty (BTKA) safety is still controversial. The aim of this study was to examine the association of blood transfusion type (pure autologous, pure allogeneic, and combined) with complication and prolonged length of stay (PLOS) following same-day BTKA. 649 consecutive patients were retrospectively identified over a two-year period. Pure allogeneic transfusions were associated with increased odds of minor complication when compared to patients who had pure autologous transfusions. No association was found between blood transfusion type and major complication or PLOS. Our results suggest that blood transfusion type may be influential in minor complication after BTKA.

Enhanced Recovery after Vascular Surgery

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.

Different patient satisfaction levels between the first and second knee in the early stage after simultaneous bilateral total knee arthroplasty (TKA): a comparison between subjective and objective outcome assessments

Background

Simultaneous bilateral total knee arthroplasty (TKA) is an effective treatment option and safe for properly selected patients. The purpose of this study was to evaluate whether patients have different satisfaction levels between the first and second knee in the early stage after simultaneous bilateral TKA.

Methods

We retrospectively reviewed 46 patients who underwent simultaneous bilateral TKA by a single surgeon in our department between March 2013 and March 2015. The surgeon typically performed first-side TKA (right knee), followed by TKA on the left knee. Tranexamic acid (TXA) (10 mg/kg) was given intravenously, and the tourniquet was released after wound closure. The preoperative KSS, ROM, and pain visual analog scale (VAS); the objective parameters including drainage volume and swelling evaluated by the circumference of the 10 cm above the patella; and the preoperative and postoperative (1st, 3rd, and 7th days) subjective parameters including pain, satisfaction VAS, and patient satisfaction of the first and second surgeries for each knee were analyzed.

Results

In simultaneous bilateral TKA, compared with the second-side TKA (left knee), the first-side TKA (right knee) had a lower mean drainage volume (p < 0.05), but the swelling of the knee was higher on the 1st, 3rd, and 7th postoperative days (p < 0.05). Moreover, the first-side TKA was scored lower in satisfaction VAS but higher in pain VAS at the 1st, 3rd, and 7th postoperative days. The patient satisfaction scores indicated 2 (4.4%) of the 46 patients scored first-side TKA higher than second-side TKA, 34 (73.9%) of the 46 patients scored second-side TKA higher than first-side TKA, and 10 (21.7%) of the 46 patients scored their satisfaction as the same for both knees.

Conclusions

This research study found that there was better patient satisfaction with the second knee in the early stage after simultaneous bilateral TKA, which may provide some considerations for surgeons choosing simultaneous bilateral total knee arthroplasty for patients with osteoarthritis in both knees.

Population-based Assessment of Intraoperative Fluid Administration Practices Across Three Surgical Specialties

OBJECTIVE

To assess the variation in hospitals' approaches to intraoperative fluid management and their association with postoperative recovery.

BACKGROUND

Despite increasing interest in goal-directed, restricted-volume fluid administration for major surgery, there remains little consensus on optimal strategies, due to the lack of institution-level studies of resuscitation practices.

METHODS

Among 64 hospitals in a state-wide surgical collaborative, we profiled fluid administration practices during 8404 intestinal resections, 22,854 hysterectomies, and 1471 abdominopelvic endovascular procedures. We computed intraoperative fluid balance, accounting for patient morphometry, crystalloid, colloid, blood products, urine, blood loss, duration, and approach. We stratified hospitals by average fluid balance quartile, and compared patterns across disciplines and associations with risk-adjusted postoperative length of stay (pLOS).

RESULTS

There was wide variation in fluid balance between hospitals (P < 0.001, all procedures), but significant within-hospital correlation across operations (Pearson rho: intestinal-hysterectomy = 0.50, intestinal-endovascular = 0.36, hysterectomy-endovascular = 0.54, all P < 0.05). Highest fluid balance hospitals had significantly longer adjusted pLOS than lowest balance hospitals for intestinal resection (6.5 vs 5.7 d, P < 0.001) and hysterectomy (1.9 vs 1.7 d, P < 0.001), but not endovascular (2.1 vs 2.3 d, P = 0.69). Risk-adjusted complication rates were not associated with fluid balance rankings.

CONCLUSIONS

Hospitals' approaches to intraoperative fluid administration vary widely, and their practice patterns are pervasive across disparate procedures. High fluid balance hospitals have 12% to 14% longer risk-adjusted pLOS for visceral abdominal surgery, independent of patient complexity and complications. These findings are consistent with evidence that isovolemic resuscitation in enhanced recovery protocols accelerates recovery of bowel function.

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

Importance

As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions.

Objective

To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions.

Design, Setting, and Participants

This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period.

Exposure

Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers.

Main Outcomes and Measures

Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care.

Results

A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period.

Conclusions and Relevance

Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

Does post-operative knee awareness differ between knees in bilateral simultaneous total knee arthroplasty? Predictors of high or low knee awareness

PURPOSE

To evaluate the difference in post-operative knee awareness between knees in patients undergoing bilateral simultaneous total knee arthroplasty (TKA) and to assess factors predicting high or low knee awareness.

METHODS

This study was conducted on 99 bilateral simultaneous TKAs performed at our institution from 2008 to 2012. All patients received one set of questionnaires [Forgotten Joint Score (FJS) and Oxford Knee Score (OKS)] for each knee. Based on the FJS, the patients' knees were divided into two groups: "best" and "worst" knees. The median of the absolute difference in FJS and OKS within each patient was calculated. Multivariate linear regression was performed to identify factors affecting FJS.

RESULTS

The difference between knees was 1 point (CI 0-5) for the FJS and 1 point (CI 0-2) for the OKS. The FJS for females increased (decreasing awareness) with increasing age. Males had the highest FJS (lowest awareness) at the age of 67. An increase in the FJS (lower knee awareness) of 12.0 points was found for Kellgren-Lawrence (K-L) grades 3 + 4 compared with K-L grades 1 + 2. A preoperative anatomical alignment of 3° valgus resulted in the lowest FJS (highest knee awareness) with decreasing knee awareness for decreasing tibio-femoral angles. Post-operative alignment did not significantly affect FJS.

CONCLUSION

Knee awareness did not differ significantly between the "best" and the "worst" knee. Bilateral simultaneous TKA can be performed without compromising the result in one of the knees. Knee awareness after primary TKA was influenced by age, gender, preoperative knee alignment, and severity of OA.

LEVEL OF EVIDENCE

III.

Morbidity and mortality after bilateral simultaneous total knee arthroplasty in a fast-track setting

Background and purpose - The safety aspects of bilateral simultaneous total knee arthroplasty (BSTKA) are still debated. In this retrospective single-center study, we investigated early morbidity and mortality following BSTKA in a modern fast-track setting. We also identified risk factors for re-admission within 90 days and for a length of stay (LOS) of more than 5 days. Patients and methods - 284 patients were selected to receive BSTKA at our institution from 2008 through 2014 in a well-described, standardized fast-track setup (Husted 2012a, b). All re-admissions within 90 days were identified and mortality rates and time until death were recorded. Transfusion rates and numbers of transfusions were also recorded. Logistic regression analysis was used to identify risk factors for re-admission within 90 days, and also for a LOS of more than 5 days. Results - 90-day mortality was 0%. 10% of the patients were re-admitted within 90 days. Median time to re-admission was 18 (3-75) days. 153 patients (54%) received postoperative blood transfusions. An ASA score of 3 was identified as an independent risk factor for re-admission within 90 days (OR = 5, 95% CI: 1.3-19) and for LOS of > 5 days (OR = 6, 95% CI: 1.6-21). Higher BMI was a weak risk factor for re-admission within 90 days. Interpretation - BSTKA in selected patients without cardiopulmonary disease in a fast-track setting appears to be safe with respect to early postoperative morbidity and mortality. Surgeons should be aware that patients with an ASA score of 3 have an increased risk of re-admission and a prolonged length of stay, while patients with higher BMI have an increased risk of re-admission following BSTKA.

Clinical Outcomes and Risks of Single-stage Bilateral Unicompartmental Knee Arthroplasty via Oxford Phase III

Background:

Osteoarthritis often affects the joint bilaterally, and the single-stage (SS) unicompartmental knee arthroplasty (UKA) is advantageous in terms of a single anesthesia administration, a short hospital stay, lower medical costs, and enhanced patient convenience. However, the complication risk of SS UKA continues to be debated. The aim of this article was to evaluate the clinical effectiveness, complications, and functional recovery of SS and two-stage (TS) UKA.

Methods:

From January 2008 to December 2013, we compared a series of 36 SS UKA with 45 TS UKA for osteoarthritis. The mean age was 65.4 years (range: 55–75 years). The mean body mass index was 25.2 kg/m² (range: 22–29 kg/m²). The pre- and post-operative Oxford Knee Scores (OKSs), complications, operative times, tourniquet times, the amount of drainage, and hemoglobin (Hb) were evaluated. The Chi-square test, Fisher's exact test, and paired and grouped t-tests were used in this study.

Results:

The mean follow-up was 50 months. No complications of death, fat embolism, deep vein thrombosis, and prosthetic infection were reported. Patients who underwent SS UKA had a shorter cumulative anesthesia time (113.5 vs. 133.0 min, P < 0.01). There were no significant variations between the values of the mean tourniquet time, the amount of drainage, pre- and post-operative Hb in the different groups. No patient required a blood transfusion. No statistical differences were found in the complications between two groups (P > 0.05). At the final follow-up, the mean OKS improved from 39.48 ± 5.69 to 18.83 ± 3.82 (P < 0.01), with no statistical differences between the two groups (P > 0.05). Patients who underwent SS UKA had a faster recovery.

Conclusions:

The single-staged UKA offers the benefits of a single anesthesia administration, reduced total anesthetic time, decreased overall rehabilitation time, and absence of an increase in perioperative mortality or complications compared with the TS bilateral UKA.

Knee awareness and functionality after simultaneous bilateral vs unilateral total knee arthroplasty

AIM: To investigate knee awareness and functional outcomes in patients treated with simultaneous bilateral vs unilateral total knee arthroplasty (TKA).

METHODS: Through a database search, we identified 210 patients who had undergone unilateral TKA (UTKA) and 65 patients who had undergone simultaneous bilateral TKA (SBTKA) at our institution between 2010 and 2012. All TKAs were cemented and cruciate retaining. The mean follow-up period was 3.2 (2 to 4) years. All the patients had symptomatic and debilitating unilateral or bilateral osteoarthritis for which all conservative and non-surgical treatments were failed, thus preoperatively the patients had poor functionality. All patients were asked to complete Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) questionnaires. The patients were matched according to age, gender, year of surgery, Kellgren-Lawrence score and pre- and postoperative overall knee alignment. The FJS and OKS questionnaire results of the two groups were then compared.

RESULTS: A mixed-effects model was used to analyze differences between SBTKA and UTKA. OKS: The mean difference in the OKS between the patients who had undergone SBTKA and those who had undergone UTKA was 1.5, which was not statistically significant (CI = -0.9:4.0, P-value = 0.228). The mean OKS of the SBTKA patients was 37.6 (SD = 9.0), and the mean OKS of the UTKA patients was 36.1 (SD = 9.9). FJS: The mean difference in the FJS between the patients who had undergone SBTKA and those who had undergone UTKA was 2.3, which was not statistically significant (CI = -6.2:10.8, P-value = 0.593). The mean FJS of the SBTKA patients was 59.9 (SD = 27.5), and the mean FJS of the UTKA patients was 57.5 (SD = 28.8).

CONCLUSION: SBTKA and UTKA patients exhibited similar joint functionality and knee awareness. Our results support the use of SBTKA in selected patients suffering from clinically symptomatic bilateral osteoarthritis.

Retrospective cohort study of an enhanced recovery programme in oesophageal and gastric cancer surgery

Introduction Enhanced recovery programmes have been established in some areas of elective surgery. This study applied enhanced recovery principles to elective oesophageal and gastric cancer surgery. Methods An enhanced recovery programme for patients undergoing open oesophagogastrectomy, total and subtotal gastrectomy for oesophageal and gastric malignancy was designed. A retrospective cohort study compared length of stay on the critical care unit (CCU), total length of inpatient stay, rates of complications and in-hospital mortality prior to (35 patients) and following (27 patients) implementation. Results In the cohort study, the median total length of stay was reduced by 3 days following oesophagogastrectomy and total gastrectomy. The median length of stay on the CCU remained the same for all patients. The rates of complications and mortality were the same. Conclusions The standardised protocol reduced the median overall length of stay but did not reduce CCU stay. Enhanced recovery principles can be applied to patients undergoing major oesophagogastrectomy and total gastrectomy as long as they have minimal or reversible co-morbidity.

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.

METHODS

A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.

RESULTS

Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.

CONCLUSIONS

Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.

Analysis of Early Postoperative Pain in the First and Second Knee in Staged Bilateral Total Knee Arthroplasty: A Retrospective Controlled Study

Objective

A retrospective analysis of early postoperative pain in the first and second knee in staged bilateral total knee arthroplasty (TKA) to provide a clinical evidence for the change of analgesic strategy.

Methods

From January 2009 to January 2013, 87 cases which meet the inclusion criterion were retrospectively reviewed. In stage TKA, the postoperative pain in the first and second knee at 24h, 48h, 72h after operation were compared using the visual analogue scale (VAS) score in the rest and maximum knee flexion position. The difference in pain scores (ΔVAS) was also compared between the second and first knee at different time intervals (less than 6 months, 6-12 months, more than 12 months).

Results

The VAS scores in the second knee were significantly higher than those in the first knee at 24h, 48h after surgery, but with no difference at 72h. The ΔVAS in the group of less than 6 months was significantly higher than of those more than 6 months, and there was no difference in ΔVAS between group of 6-12 months and group of more than 12 months.

Conclusions

Patient receiving staged bilateral TKA experiences greater postoperative pain within 48h after operation in the second knee than in the first knee, which can provide a clinical evidence to enhance the analgesic strategy in the second operation of the staged bilateral TKA. And for the management of postoperative pain in staged bilateral TKA, it’s better to recommend that the interval between two operations should be more than 6 months, which may reduce the postoperative pain in the second knee, improve patient satisfaction, and speed up patient‘s rehabilitation process.

Meta-analysis of efficacy and safety of fast-track surgery in gastrectomy for gastric cancer

BACKGROUND

Fast-track surgery (FTS) is a promising program for surgical patients and has been applied to several surgical diseases. FTS is much superior to conventional perioperative care. Our aim was to evaluate and compare the safety and efficacy of FTS and conventional perioperative care for patients undergoing gastrectomy using a systematic review.

METHODS

We searched the literature in PubMed, SCOPUS, and EMBASE up to November 2013. No language restriction was applied. Weighted mean differences (WMDs) and odds ratios (ORs) with their 95 % confidence intervals (CIs) were used for analysis by a fixed or a random effects model according to the heterogeneity assumption.

RESULTS

In the present meta-analysis, we included five randomized controlled trials and one controlled clinical trial from five studies. Compared with conventional care, FTS shortened the duration of flatus (WMD -21.08; 95 % CI -27.46 to -14.71, z = 6.48, p < 0.00001 in the open surgery group; WMD -8.20; 95 % CI -12.87 to -3.53, z = 3.44, p = 0.0006 in the laparoscopic surgery group), accelerated the decrease in C-reactive protein (WMD -15.56; 95 % CI 21.28 to 9.83, z = 5.33, p < 0.00001), shortened the postoperative stay (WMD -2.00; 95 % CI -2.69 to -1.30, z = 5.64, p < 0.00001), and reduced hospitalization costs (WMD -447.72; 95 % CI -615.92 to -279.51, z = 5.22, p < 0.00001). FTS made no significant difference in operation times (p = 0.93), intraoperative blood loss (p = 0.79), or postoperative complications (p = 0.07).

CONCLUSIONS

Based on current evidence, the FTS protocol was feasible for gastric cancer patients who underwent gastrectomy (distal subtotal gastrectomy, proximal subtotal gastrectomy, or radical total gastrectomy) via open or laparoscopic surgery. Larger studies are needed to validate our findings.

Simultaneous bilateral total knee arthroplasty in severe hemophilia: a retrospective cost-effectiveness analysis

INTRODUCTION

Simultaneous bilateral total knee arthroplasty (TKA) is proposed in the general population as an alternative to staged bilateral TKA and has the advantage of reducing costs with equivalent complication rates. The aim of this study was to evaluate the cost-effectiveness of this alternative in a population of patients with severe hemophilia.

HYPOTHESIS

Simultaneous bilateral TKA is less expensive than staged bilateral TKA.

MATERIALS AND METHODS

We performed a retrospective case control study in patients with severe hemophilia A to compare the direct costs of coagulation factors, the length of hospital stay and sick leave as well as the clinical outcome (KKS) of simultaneous bilateral TKA (group 1; G1: 5 patients) and staged bilateral TKA (group 2; G2: 12 patients).

RESULTS

The mean cost of coagulation factors was 65,880 € in G1 and 139,000 € in G2 (P<0.001). The length of the hospital stay (24 days vs 44 cumulative days, respectively) and sick leave (105 days vs 183 cumulative days, respectively) was significantly reduced in G1. There was no significant difference in clinical outcome at the final follow-up. One patient in G2 had a late knee infection.

DISCUSSION

Simultaneous bilateral TKA in severe hemophilia is associated with lower costs than staged bilateral TKA with equivalent clinical results.

LEVEL OF EVIDENCE

Level 3, case control study.

Early morbidity after simultaneous and staged bilateral total knee arthroplasty

PURPOSE

The aim of this nationwide study was to investigate the early morbidity after bilateral simultaneous and staged total knee arthroplasty (TKA) in order to clarify potential benefits of a well-established fast-track regime.

METHODS

The Danish National Patient Registry was searched for all bilateral simultaneous and staged TKA procedures from 2010 to 2011. The staged procedures were defined as two separate procedures done within 0-6 months or within 7-18 months.

RESULTS

A total of 157 patients had bilateral simultaneous TKA, 346 patients had bilateral staged TKA within 0-6 months and 292 patients had bilateral staged TKA within 7-18 months. The median length of stay in hospital (LOS) was 4 days (interquartile range, IQR: 3) after bilateral simultaneous TKA versus cumulated LOS of 6 days (IQR: 3) in both of the bilateral staged groups (p < 0.001). There were no deaths after bilateral simultaneous TKA versus three deaths (0.9 and 1.0 %) in each of the bilateral staged groups within 90 days of surgery (n.s.). The total readmission rate within 30 days of surgery was lower after bilateral simultaneous TKA (7 %, CI 4.0-12.0) and bilateral staged TKA within 0-6 months (9 %, CI 6.4-12.4) compared with 14 % (CI 11.5-20.1) after bilateral staged TKA within 7-18 months.

CONCLUSIONS

The results from this nationwide study indicate that bilateral simultaneous TKA can safely be performed in a fast-track set-up.

A systematic review of enhanced recovery care after colorectal surgery in elderly patients

AIM

Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old.

METHOD

A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence.

RESULTS

Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations.

CONCLUSION

ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.

A reliable, valid and responsive questionnaire to score the impact of knee complaints on work following total knee arthroplasty: the WORQ

The Work, Osteoarthritis or joint-Replacement Questionnaire (WORQ) was developed to assess physical difficulty experienced in work before or following total knee arthroplasty (TKA). Thirteen questions were designed. The WORQ was tested for internal consistency by factor analysis, internal reliability (Crohnbach's α), and construct validity. A test-retest reproducibility was performed for analyzing standard error of measurement (SEM agreement), reliability (ICC) and smallest detectable change (SDC) in individuals and groups. Lastly responsiveness (standardized response means [SRM]), floor and ceiling effects and interpretability (minimal important change [MIC]) were analyzed. It is shown that the WORQ is a reliable, valid and responsive questionnaire that can be used to evaluate the impact of knee complaints following TKA on patients' ability to work.

Total knee arthroplasty and the unforeseen impact on return to work: a cross-sectional multicenter survey

The number of patients receiving a TKA during working life is increasing but little is known about the impact of TKA on patients' reintegration into the workplace. In this cross-sectional survey it was found that 173 of 480 responders worked within 2 years prior to surgery. Sixty-three percent of the working patients stopped within two weeks prior to surgery and 102 patients returned within 6 months. One third never returned to work. Activities that most improved were operating foot pedals, operating vehicles, standing and walking on level terrain. Activities that least improved were kneeling, crouching and clambering. Fifty patients scored 5 or less on the Work Ability Index. Thirty patients were dissatisfied. TKA significantly, but unequally, reduces difficulties in carrying out knee-burdening work activities.

A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery

INTRODUCTION

Orthopaedic enhanced recovery after surgery (ERAS) providers are encouraged to estimate the actual benefit of ERAS according to the patient's opinion by using patient generated data alongside traditional measures such as length of stay. The aim of this paper was to systemically review the literature on the use of patient generated information in orthopaedic ERAS across the whole perioperative pathway.

METHODS

Publications were identified using Embase(™), MEDLINE(®), AMED, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library and the British Nursing Index. Search terms related to experiences, acceptance, satisfaction or perception of ERAS and quality of life (QoL).

FINDINGS

Of the 596 abstracts found, 8 papers were identified that met the inclusion criteria. A total of 2,208 patients undergoing elective hip and knee arthroplasty were included. Patient satisfaction was reported in 6 papers. Scores were high in all patients and not adversely affected by length of stay. QoL was reported in 2 papers and showed that QoL scores continued to increase up to 12 months following ERAS. Qualitative methods were used in one study, which highlighted problems with support following discharge. There is a paucity of data reporting on patient experience in orthopaedic ERAS. However, ERAS does not compromise patient satisfaction or QoL after elective hip or knee surgery. The measurement of patient experience should be standardised with further research.

Do patients return to work after total knee arthroplasty?

BACKGROUND

Although there is extensive literature supporting a high success rate, there are limited data on return to work after total knee arthroplasty (TKA).

QUESTIONS/PURPOSES

We sought to determine (1) the percentage of patients who returned to work after TKA; (2) what percentage returned to their original job; (3) whether this varied based on the physical job demand category; and (4) whether there were differences between men and women in terms of the likelihood of returning to work after TKA.

METHODS

A multicenter study was conducted of patients of working age (18-60 years) who underwent TKA 1 to 5 years previously. An independent third-party survey center with expertise in collecting healthcare data for state and federal agencies collected the data. Definitions from the US Department of Labor's Dictionary of Occupational Titles were used to determine physical job demand categories of sedentary, light, medium, heavy, and very heavy. Complete data were collected on 661 patients undergoing TKA (average age 54 years, 61% women).

RESULTS

Seventy-five percent (494 of 661) were employed in the 3 months before their TKA and 98% (482 of 494) returned to work after surgery; 89% (440 of 494) returned to the same job. Before surgery, physical demand categories of the patients' jobs were sedentary 12%, light 10%, medium 24%, heavy 24%, and very heavy 30%. The return to work rate for those employed during the 3 months before surgery by physical demand category was sedentary 95%, light 91%, medium 100%, heavy 98%, and very heavy 97%. Men were more likely than women to have worked within the 3 months before TKA but there was no difference between sexes in return to work after TKA.

CONCLUSIONS

In this group of young patients, most returned to work at their usual occupation after TKA.

Clinical outcomes of bilateral single-stage unicompartmental knee arthroplasty

BACKGROUND

Deciding whether to treat patients with bilateral arthritis with two-stage or bilateral single-stage arthroplasties is a cause of considerable debate in orthopaedic surgery.

METHODS

A total of 394 cemented Unicompartmental Knee Arthroplasties (UKA) were performed in this unit between 2006 and 2010. A retrospective review identified 38 patients (76 knees) who underwent bilateral Single-Stage Sequential UKA, performed by a single surgeon.

RESULTS

The mean BMI was 29.8 and the majority of patients were ASA grade 2. The mean duration of follow-up was 30 months. The mean total tourniquet time was 83 min. The mean post-operative haemoglobin was 11.8 and no patient required blood transfusion. The mean time to mobilisation was 18 h and the average length of stay was 3.5 days. This compares favourably with an institutional average length of stay of two days for a single UKA. There was a significant improvement in the mean pre- to post-operative OKS (from 14 to 34, p<0.0001). One patient required operative fixation of a tibial plateau fracture after sustaining a mechanical fall two months following surgery. There were no other major complications, including thrombo-embolic events or deep infections. Two patients required excision of a superficial suture granuloma.

CONCLUSIONS

Bilateral Single-Stage Sequential UKAs provide significant improvement in patient function and can be performed safely with a low complication rate. Patients can benefit from a single hospital admission and anaesthetic whilst the shorter total in-patient stay reduces costs incurred by the hospital.

LEVEL OF EVIDENCE

IV.

A cost-utility analysis comparing the cost-effectiveness of simultaneous and staged bilateral total knee arthroplasty

BACKGROUND

The safety and efficacy of simultaneous or staged bilateral total knee arthroplasty have long been debated among orthopaedic surgeons. Advocates for simultaneous bilateral total knee arthroplasty posit that the benefits of decreased costs and recovery time, with no difference in functional outcomes, outweigh the economic costs of potential complications. The purpose of the study was to conduct a cost-utility analysis comparing simultaneous bilateral total knee arthroplasty with staged bilateral total knee arthroplasty.

METHODS

A Markov model was designed to compare the cost-effectiveness of simultaneous bilateral total knee arthroplasty with that of staged bilateral total knee arthroplasty. Nationwide Inpatient Sample data sets from 2004 to 2007 were used to identify 24,574 simultaneous and 382,496 unilateral procedures. On the basis of the codes of the International Classification of Diseases, Ninth Revision, Clinical Modification, perioperative complications were categorized as minor, major, and mortality, and respective probability values were calculated. Nationwide Inpatient Sample data were used to determine hospital costs conditional on procedure type and complications. Rehabilitation costs, anesthesia costs, and heath utilities were estimated from the literature. To minimize selection bias, propensity score matching was used to match the groups on comorbid conditions, socioeconomic variables, and hospital characteristics.

RESULTS

Using the matched sample, all complication rates were higher for the staged group. The estimated mean cost (in 2012 U.S. dollars) was $43,401 for simultaneous bilateral total knee arthroplasty compared with $72,233 for staged bilateral total knee arthroplasty. The quality-adjusted life years gained were 9.31 for simultaneous bilateral total knee arthroplasty and 9.29 for staged bilateral total knee arthroplasty. On the basis of these matched results, simultaneous bilateral total knee arthroplasty dominated staged bilateral total knee arthroplasty with lower costs and better outcomes.

CONCLUSIONS

On the basis of this analysis, simultaneous bilateral total knee arthroplasty is more cost-effective than staged bilateral total knee arthroplasty, with lower costs and better outcomes for the average patient. These data can inform shared medical decision-making when bilateral total knee arthroplasty is indicated.

Staged bilateral total knee arthroplasty: does history dictate the future?

A retrospective cohort study of 668 staged bilateral TKA patients was conducted to determine first-side versus second-side subjective and objective outcomes. Improvement in patient perceived function, measured by one-year Oxford Score (OKS) was defined by a minimal clinically important difference of >5 points in OKS. Results indicate that patients who had a minimal clinically important improvement (MCII) on the first-side have a significantly greater chance of maintaining or improving benefit with second-side TKA (OR 3.2; 95% CI 1.63-6.22; P=0.000). Of those with no clinical improvement (NCI), 71.4% achieved MCII on the second-side, while 28.6% remained NCI (P=0.000). Patients who do not initially benefit from first-side TKA should not be denied second-side staged-TKA as they still have a significant chance of achieving an MCII.

Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients

AIM: To assess the impact of fast-track surgery (FTS) on hospital stay, cost of hospitalization and complications after radical total gastrectomy.

METHODS: A randomized, controlled clinical trial was conducted from November 2011 to August 2012 in the Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, the Fourth Military Medical University. A total of 122 gastric cancer patients who met the selection criteria were randomized into FTS and conventional care groups on the first day of hospitalization. All patients received elective standard D2 total gastrectomy. Clinical outcomes, including duration of flatus and defecation, white blood cell count, postoperative pain, duration of postoperative stay, cost of hospitalization and complications were recorded and evaluated. Two specially trained doctors who were blinded to the treatment were in charge of evaluating postoperative outcomes, discharge and follow-up.

RESULTS: A total of 119 patients finished the study, including 60 patients in the conventional care group and 59 patients in the FTS group. Two patients were excluded from the FTS group due to withdrawal of consent. One patient was excluded from the conventional care group because of a non-resectable tumor. Compared with the conventional group, FTS shortened the duration of flatus (79.03 ± 20.26 h vs 60.97 ± 24.40 h, P = 0.000) and duration of defecation (93.03 ± 27.95 h vs 68.00 ± 25.42 h, P = 0.000), accelerated the decrease in white blood cell count [P < 0.05 on postoperative day (POD) 3 and 4], alleviated pain in patients after surgery (P < 0.05 on POD 1, 2 and 3), reduced complications (P < 0.05), shortened the duration of postoperative stay (7.10 ± 2.13 d vs 5.68 ± 1.22 d, P = 0.000), reduced the cost of hospitalization (43783.25 ± 8102.36 RMB vs 39597.62 ± 7529.98 RMB, P = 0.005), and promoted recovery of patients.

CONCLUSION: FTS could be safely applied in radical total gastrectomy to accelerate clinical recovery of gastric cancer patients.

Simultaneous versus staged bilateral unicompartmental knee replacement

We prospectively followed 171 patients who underwent bilateral unicompartmental knee replacement (UKR) over a period of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral procedure and 47 (27.5%) underwent a staged procedure. The mean cumulative operating time and length of hospital stay were both shorter in the simultaneous group, by 22.5 minutes (p < 0.001) and three days (p < 0.001), respectively. The mean reduction in haemoglobin level post-operatively was greater by 0.15 g/dl in the simultaneous group (p = 0.023), but this did not translate into a significant increase in the number of patients requiring blood transfusion (p = 1.000). The mean hospital cost was lower by $8892 in the simultaneous group (p < 0.001). There was no significant difference in the rate of complications between the groups, and at two-year follow-up there was no difference in the outcomes between the two groups.

We conclude that simultaneous bilateral UKR can be recommended as an appropriate treatment for patients with bilateral medial compartment osteoarthritis of the knee.

Cite this article: Bone Joint J 2013;95-B:788–92.

No effect of fibrin sealant on drain output or functional recovery following simultaneous bilateral total knee arthroplasty: a randomized, double-blind, placebo-controlled study

BACKGROUND AND PURPOSE

Blood loss after total knee arthroplasty (TKA) may lead to anemia, blood transfusions, and increased total costs. Also, bleeding into the periarticular tissue may cause swelling and a reduction in quadriceps strength, thus impairing early functional recovery. In this randomized, double-blind, placebo-controlled study, we analyzed the possible effect of fibrin sealant on blood loss and early functional recovery in a fast-track setting.

METHODS

24 consecutive patients undergoing bilateral simultaneous TKA were included. 10 mL of fibrin sealant (Evicel) was sprayed onto one knee whereas the contralateral knee had saline. Drain output, the primary outcome, was measured from knee drains removed exactly 24 h after surgery. Secondary outcomes (knee swelling, pain, strength of knee extension, and range of movement (ROM)) were evaluated up to 21 days after surgery.

RESULTS

The drain output in knees treated with fibrin sealant and placebo was similar (582 mL and 576 mL, respectively). Likewise, no statistically significant differences were found between groups regarding swelling, pain, strength of knee extension, and ROM.

INTERPRETATION

Fibrin sealant as a local hemostatic in TKA showed no benefit in reducing drain output or in facilitating early functional recovery when used with a tourniquet, tranexamic acid, and a femoral bone plug.