Epidemiology of total hip and knee replacement: a cross-sectional study

Epidemiology of hip & knee replacement across Pakistan: Multicenter cross-sectional study

Objective

To know about the predictive prevalence of hip and knee arthroplasty across Pakistan.

Methods

It is retrospective cross-sectional study with data collection from Pakistan National Joint Registry (PNJR) of number of hip and knee arthroplasty cases in seven years (2014-2021). Fourteen high volume centers across Pakistan who consented for data publication were included. Stata version 16 was used for data analysis. Mean & standard deviation was reported for quantitative variable & frequency and proportion were reported for qualitative variables.

Results

Our results showed a total of 9572 people had total knee replacement in last seven years from 2014-2021 with the rate of 9.57/100,000 population. Mean age of the patient was 61.7±8.95 with 69.5% patients being female and 30.5% being male. Our results showed a total of 2265 people had total hip replacement in last seven years from 2014-2021with the rate of 2.26/100,000 population. Mean age of the patient was 50.7±15.4 with 62% patients being male and 38% being female.

Conclusion

This is the first epidemiological study in Pakistan on the rates of hip and knee arthroplasty cases in Pakistan based on registry data, showing that more knee arthroplasty cases are being performed as compared to hip arthroplasty.

Effect of Total Hip Arthroplasty with Ceramic Acetabular Component on Clinical, Radiographic and Functional Parameters in Older Patients with Hip Osteoarthritis: Two-Year Follow-Up

Background: Total hip arthroplasty (THA) is a widely used surgical procedure to reduce pain and improve function and quality of life in patients with hip disorders. The most common condition that leads to THA is osteoarthritis, with most surgeries being performed to treat severe osteoarthritis with pain and functional limitations. Despite the evident success of THA, the search for its improvement and better results, especially in the long term, continues, especially in older patients, for which there is still little scientific evidence. Objective: To evaluate the clinical, radiological, and functional aspects preoperatively and two years after THA with a ceramic acetabular component device in older patients with hip osteoarthritis. Methods: A retrospective cohort study was conducted to evaluate 65 older individuals who underwent THA of the hip with an acetabular component (MD® ceramic head with a ceramic acetabular insert) associated with the MD6® Phenom® femoral rod type, in Hospital of the Luz, São Paulo/SP, between 2018 and 2019. Anthropometric and clinical information about the operative procedure and two years follow-up were collected from the patients’ medical records. For the clinical-functional evaluation, the Harris Hip Score (HHS) questionnaire and hip movement goniometry were applied. For the radiographic parameters, the following were evaluated: the positioning of the acetabular component, the Zone of DeLee and the offset of the femoroacetabular component. Results: There was a higher prevalence of performing THA in males (53.8%). Preoperative and two-year postoperative radiographic parameters of surgical treatment for THA showed maintenance of the acetabular (p = 0.083) and femoral (p = 0.102) positioning angles and increased functionality (p < 0.001) and joint mobility of the hip (p = 0.001) with reduced pain after two years of THA. Complications related to dislocation, loosening, infection, and inadequate positioning of the implant were low, ranging from 1.5 to 3%. Conclusion: Older people who underwent cementless THA with an ceramic acetabular component device, in a two-year follow-up, showed effectiveness in improved clinical, radiological, and functional aspects.

Avaliação dos fatores de risco relacionados ao tempo de internação e às complicações pós-operatórias em pacientes submetidos a artroplastia total primária do joelho

Objetivo Avaliar os fatores de risco relacionados a um tempo de internação mais longo e às complicações pós-operatórias precoces (primeiros 30 dias após a cirurgia) em pacientes submetidos a artroplastia total do joelho (ATJ).

Materiais e Métodos Este é um estudo transversal com coleta de dados de pacientes submetidos a ATJ em um hospital privado entre 2015 e 2019. Os seguintes dados foram coletados: idade, gênero, índice de massa corporal, e comorbidades clínicas. Também coletamos dados intraoperatórios, como o grau na classificação da American Society of Anesthesiologists (ASA) e a duração da cirurgia, além do tempo de internação, as complicações pós-operatórias, e a readmissão em 30 dias. Os possíveis fatores de risco associados a um tempo de internação mais longo e às taxas de complicações pós-operatórias foram investigados por meio de modelos estatísticos.

Resultados Os pacientes mais velhos, com graus mais elevados na classificação da ASA ou que sofreram complicações pós-operatórias, ficaram internados por mais tempo. Para cada aumento em um ano de idade, esperamos que o tempo de internação seja multiplicado por 1,008 (intervalo de confiança de 95% [IC95%]: 1,004 a 1,012; p < 0,001). Em pacientes de grau III na classificação da ASA, espera-se que o tempo seja multiplicado por 1,297 (IC95%: 1,083 a 1,554; p = 0,005) em comparação com pacientes de grau I. Em pacientes com complicações pós-operatórias, espera-se que o tempo seja multiplicado por 1,505 (IC95%: 1,332 a 1,700; p < 0,001) em comparação com pacientes sem complicações.

Conclusão Este estudo demonstrou que, em pacientes submetidos a ATJ primária, características pré-operatórias, como idade avançada e grau ≥ III na classificação da ASA, e o desenvolvimento de complicações pós-operatórias predizem o aumento do tempo de internação hospitalar de forma independente.

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator is not reliable in predicting complications and length of stay after primary total hip arthroplasty at an institution implementing clinical pathways

INTRODUCTION

The authors aimed to: (1) determine how length of stay (LOS) and complication rates changed over the past 10 years, in comparison to values estimated by the ACS-NSQIP surgical risk calculator, at a single private institution open to external surgeons; and (2) determine preoperative patient factors associated with complications.

METHODS

We retrospectively assessed 1018 consecutive patients who underwent primary elective THA over 10 years. We excluded 87 with tumours and 52 with incomplete records. Clinical data of the remaining 879 were used to determine real LOS and rate of 9 adverse events over time, as well as to estimate these values using the risk calculator. Its predictive reliability was represented on receiver operating characteristic curves. Multivariable analyses were performed to determine associations of complications with age, sex, ASA score, diabetes, hypertension, heart disease, smoking and BMI.

RESULTS

Over the 10-year period, real LOS and real complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time. The overall estimated and real rates of any complication were respectively 3.3% and 2.8%. The risk calculator had fair reliability for predicting any complications (AUC 0.72). Overall estimated LOS was shorter than the real LOS in 764 (86.9%) patients. Multivariable analysis revealed risks of any complication to be greater in patients aged ⩾75 (OR = 4.36, p = 0.002), and with hypertension (OR = 3.13, p = 0.016).

CONCLUSIONS

Since the implementation of clinical pathways at our institution, real LOS and complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time, which could lead some clinicians to reconsider their discharge criteria, knowing that advanced age and hypertension increased risks of encountering complications.

Use of human induced pluripotent stem cells for cartilage regeneration in vitro and within chondral defect models of knee joint cartilage in vivo: a Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic literature review

BACKGROUND AIMS

Articular cartilage has limited regenerative ability when damaged through trauma or disease. Failure to treat focal chondral lesions results in changes that inevitably progress to osteoarthritis. Osteoarthritis is a major contributor to disability globally, which results in significant medical costs and lost wages every year. Human induced pluripotent stem cells (hiPSCs) have long been considered a potential autologous therapeutic option for the treatment of focal chondral lesions. Although there are significant advantages to hiPSCs over other stem cell options, such as mesenchymal and embryonic stem cells, there are concerns regarding their ability to form bona fide cartilage and their tumorgenicity in vivo.

METHODS

The authors carried out a systematic literature review on the use of hiPSCs to produce differentiated progeny capable of producing high-quality cartilage in vitro and regenerate cartilage in osteochondral defects in vivo in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight studies were included in the review that used hiPSCs or their derived progeny in xenogeneic transplants in animal models to regenerate cartilage in osteochondral defects of the knee joint. The in vitro-differentiated, hiPSC-derived and in vivo defect repair ability of the hiPSC-derived progeny transplants were assessed.

RESULTS

Most studies reported the generation of high-quality cartilage-producing progeny that were able to successfully repair cartilage defects in vivo. No tumorigenicity was observed.

CONCLUSIONS

The authors conclude that hiPSCs offer a valuable source of cartilage-producing progeny that show promise as an effective cell-based therapy in treating focal chondral lesions.

Clinical and Molecular Spectrum of Nonsyndromic Early-Onset Osteoarthritis

OBJECTIVE

Osteoarthritis (OA) is the most common joint disease worldwide. The etiology of OA is varied, ranging from multifactorial to environmental to monogenic. In a condition called early-onset OA, OA occurs at an earlier age than is typical in the general population. To our knowledge, there have been no large-scale genetic studies of individuals with early-onset OA. The present study was undertaken to investigate causes of monogenic OA in individuals with nonsyndromic early-onset OA.

METHODS

The study probands were 45 patients with nonsyndromic early-onset OA who were referred to our skeletal disease center by skeletal dysplasia experts between 2013 and 2019. Criteria for early-onset OA included radiographic evidence, body mass index ≤30 kg/m² , age at onset ≤50 years, and involvement of ≥1 joint site. Molecular analysis was performed with a next-generation sequencing panel.

RESULTS

We identified a genetic variant in 13 probands (29%); the affected gene was COL2A1 in 11, ACAN in 1, and SLC26A2 in 1. After familial segregation analysis, 20 additional individuals were identified. The mean ± SD age at onset of joint pain was 19.5 ± 3.9 years (95% confidence interval 3-47). Eighteen of 33 subjects (55%) with nonsyndromic early-onset OA and a genetic variant had had at least 1 joint replacement (mean ± SD age at first joint replacement 41 ± 4.2 years; mean number of joint replacements 2.6 per individual), and 21 (45%) of the joint replacement surgeries were performed when the patient was <45 years old. Of the 20 patients age >40 years, 17 (85%) had had at least 1 joint replacement.

CONCLUSION

We confirmed that COL2A1 is the main monogenic cause of nonsyndromic early-onset OA. However, on the basis of genetic heterogeneity of early-onset OA, we recommend next-generation sequencing for all individuals who undergo joint replacement prior to the age of 45 years. Lifestyle recommendations for prevention should be implemented.

Synovium-Derived Mesenchymal Stem Cell Transplantation in Cartilage Regeneration: A PRISMA Review of in vivo Studies

Articular cartilage damaged through trauma or disease has a limited ability to repair. Untreated, focal lesions progress to generalized changes including osteoarthritis. Musculoskeletal disorders including osteoarthritis are the most significant contributor to disability globally. There is increasing interest in the use of mesenchymal stem cells (MSCs) for the treatment of focal chondral lesions. There is some evidence to suggest that the tissue type from which MSCs are harvested play a role in determining their ability to regenerate cartilage in vitro and in vivo. In humans, MSCs derived from synovial tissue may have superior chondrogenic potential. We carried out a systematic literature review on the effectiveness of synovium-derived MSCs (sMSCs) in cartilage regeneration in in vivo studies in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Twenty studies were included in our review; four examined the use of human sMSCs and 16 were conducted using sMSCs harvested from animals. Most studies reported successful cartilage repair with sMSC transplantation despite the variability of animals, cell harvesting techniques, methods of delivery, and outcome measures. We conclude that sMSC transplantation holds promise as a treatment option for focal cartilage defects. We believe that defining the cell population being used, establishing standardized methods for MSC delivery, and the use of objective outcome measures should enable future high quality studies such as randomized controlled clinical trials to provide the evidence needed to manage chondral lesions optimally.

Evaluation of Acute Pain in Patients Undergoing Total Hip Arthroplasty: A Cohort Study

PURPOSE

To evaluate pain levels in patients who underwent total hip arthroplasty (THA) using the Nursing Outcomes Classification (NOC).

METHODS

Prospective cohort study conducted in the surgical hospitalization units of a university hospital in southern Brazil. Twenty-four patients were evaluated and followed-up for four consecutive days after THA.

FINDINGS

A significant difference was found between the first and last evaluations for the outcome pain level (2102). Two indicators also showed statistically significant differences overtime.

CONCLUSIONS

The NOC outcome and indicators demonstrated the different pain levels of patients who underwent THA.

IMPLICATIONS FOR NURSING PRACTICE

The NOC system is applicable to clinical practice, because it facilitated the follow-up of patient progression.

Study of the evolution and variability of nontraumatic orthopedic surgeries in Brazil-9 years of follow-up: A database study

In Brazil, there are no epidemiological statistics that map nontraumatic orthopedic injuries, their rate of variability, distribution by specialty, fatality rate, and the economic impact that these lesions and their consequences can bring to the country. The objective of this study was to evaluate the rates of variability for skills, deaths, mortality, and the economic impact of nontraumatic orthopedic surgeries in Brazil from 2008 to 2016.This is a descriptive study conducted through the analysis of data relating to the indicators of hospital production regarding orthopedic procedures of the Department of Informatics of the Unified Health System (Departamento de Informática do Sistema Único de saúde-DATASUS) between 2008 and 2016. The level of significance was 5%.There was a predominance of hospitalizations for surgery of the lower limbs, which also resulted in the largest number of deaths. The surgical mortality rate recorded for the hip also needs to be considered. In general, there is a national increase in the number of orthopedic surgeries performed, accompanied by a concomitant increase in the number of deaths and mortality of the population exposed.We observed a growing demand for hospitalization with a consequent increase in lethality and deaths. We can conclude that between 2008 and 2016, the number of hospitalizations for elective nontraumatic orthopedic surgical procedures increased significantly, driven mainly by lower limb surgeries, along with the cost of the Unified Health System (Sistema Único de Saúde-SUS) for these surgeries.

Comparison of intravenous and oral acetaminophen for pain control after total knee and hip arthroplasty: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy between intravenous and oral acetaminophen as adjunct to multimodal analgesia regimens for pain management after total knee and hip arthroplasties.

METHODS

We conduct electronic searches of Medline (1966-2017.09), PubMed (1966-2017.09), Embase (1980-2017.09), ScienceDirect (1985-2017.09), and the Cochrane Library. Only randomized controlled trials (RCTs) are included. The quality assessment is performed according to the Cochrane systematic review method. Fixed/random effect model is adopted according to the heterogeneity tested by I statistic. Meta-analysis is performed using Stata 11.0 software.

RESULTS

Two RCTs are included involving 236 patients. The present meta-analysis demonstrated that there were no significant differences between groups regarding pain scores at 12, 24, or 48 hours. No significant differences were observed in terms of opioid consumption at 12, 24, or 48 hours after arthroplasties.

CONCLUSION

Intravenous acetaminophen to multimodal analgesia dose not demonstrate a significant benefit in reducing pain and opioid consumption compared oral formulation after total knee arthroplasty and total hip arthroplasty. Higher-quality RCTs are required for further research.

PROFILE OF PATIENTS RECEIVING TOTAL KNEE ARTHROPLASTY: A CROSS-SECTIONAL STUDY

OBJECTIVE

To describe the epidemiological profile, presented deformities, associated comorbidities, and impact on quality of life in patients with knee osteoarthritis. This study was conducted in a philanthropic hospital in Fortaleza from 2014 to 2015.

METHODS

Data were collected from medical records, epidemiological forms, and by applying the Lequesne index questionnaire, which contains several questions related to pain, discomfort and functional limitation to assess the severity of symptoms.

RESULTS

Females were more prevalent (76.7%), as were patients over 65 years of age (61.6%) and non-whites (81.6%). As for comorbidities, 83.3% had hypertension and 31.7% had diabetes. Of the total, 76.5% cases were genu varum, and 23.5% genu valgum. According to the Lequesne index findings, 61.6% cases were "extremely severe," and women had higher scores.

CONCLUSION

Females were more prevalent and whites were less prevalent. The most frequent comorbidity was hypertension. Female and elderly patients have more severe disease according to Lequesne index score, and these findings were statistically significant. Level of Evidence II, Prospective Study.

Is Single-stage Revision Safe Following Infected Total Knee Arthroplasty? A Critical Review

With the improvement in outcomes and modern prosthesis design, total knee arthroplasty (TKA) has now become a commonly performed surgery. It is postulated that a total of 2-5% of the primary and revision TKA becomes infected every year, requiring a revision procedure which to date is the conventional two-stage revision. The diagnosis and treatment of these periprosthetic infections is a major and challenging task, as it requires precise identification of the pathogen, meticulous debridement, and postoperative rehabilitation. To date, there have been very few studies in existing literature comparing the outcomes of single-stage versus two-stage procedure in infected TKA. The aim of the review was to provide the clinicians an insight into the outcome of the single-stage procedure compared to two-stage procedures and to suggest ways to improve the results further. In the following critical review, a total of 669 cases that underwent either a single or two-stage revision for infected TKA were studied. The postoperative functional scores were comparable in most studies during the early postoperative period. Our data supports the use of a single-stage revision surgery in infected TKA as an alternative to a conventional two-stage procedure. However, larger prospective and multicentric trials are required to validate our findings.

Incidence of delirium in postoperative patients treated with total knee and hip arthroplasty

Summary Introduction: Delirium is a common disorder that can potentiate mortality and comorbidity rates of patients hospitalized in intensive care units. Patients undergoing major orthopedic surgeries, such as knee and hip arthroplasty, are particularly vulnerable as they often have multiple risk factors for this disorder. Method: Descriptive study of the incidence of delirium in patients treated with total knee and hip arthroplasty, given the advanced age and comorbidities in this population. We evaluated the medical records of patients who had previously undergone the designated surgeries for identification of postoperative delirium. Results: We observed in this study an incidence of 8.92% of delirium, mostly affecting females with a mean age of 73 years and hypertension. Conclusion: The incidence of delirium in our study is similar to that observed in the general population, according to the literature. We found no correlation with sleep disorders, smoking or diabetes mellitus in this study, even though the importance of these factors for the onset of delirium is well-established in the literature.

CLINICAL DEMOGRAPHIC CHARACTERISTICS OF TOTAL KNEE ARTHROPLASTY IN A UNIVERSITY HOSPITAL

OBJECTIVE

To assess socio-demographic characteristics of patients undergoing total knee arthroplasty (TKA) in a public university hospital, evaluating the outcome infection and associated factors.

METHOD

A retrospective study was carried out with 78 patients undergoing TKA, from 2013 to 2014. The socio-demographic and clinical characteristics of the patients were collected. Comparison between infected and non-infected patients was performed to find out which variables were possibly associated to this complication.

RESULT

Of 81 arthroplasties performed, patients were older (mean age 64 years), women (79%), with primary osteoarthritis as main etiology (87.6%) and most had comorbidities (82.7%). Infection occurred in 16% of patients, and this outcome associated with age older than 65 years (p=0.023) and the occurrence of deep vein thrombosis (p=0.027).

CONCLUSION

Patients undergoing TKA are mostly elderly women with primary osteoarthritis in the knee and comorbidities who developed infection in 16% of cases. More studies need to be conducted aimed at creating specific protocols in order to improve the quality of clinical practice. Level of Evidence III, Retrospective Comparative Study.

Total hip arthroplasty complications in patients with or without controlled diabetes mellitus during hospitalization

Introduction

Total hip arthroplasty (THA) is a procedure that aims to restore the function of the hip joint. Diabetes mellitus (DM) is one of the most prevalent comorbidities among patients undergoing THA. DM involves various immunological and metabolic aspects, which lead to limitations and surgical complications.

Objective

To evaluate the association between THA complications and controlled DM during hospitalization period.

Methods

Cross-sectional research through the analysis of retrospective records of a private hospital in Salvador, Bahia. The chi-squared and Fisher's exact tests were used in SAS statistical program.

Results

Most patients were elderly females. The most prevalent comorbidities in the sample were hypertension and diabetes. The most frequent underlying pathology in the sample was coxarthrosis; among patients with DM, it was femoral neck fracture. The most common complications were changes in the hemolymphopoietic system, among which anemia was the most frequent complication. Cardiovascular, nervous, and blood glucose complications were positively associated with controlled DM. In turn, hemolymphopoietic, genitourinary, digestive, electrolyte, and infectious complications were not associated with DM. Having DM was a protective factor for thermal complications. There was no statistically significant difference between patients that had or did not have DM in each complication group studied.

Conclusion

Patients with controlled DM did not present more complications than those without DM during hospitalization in the post THA.

Characterization of hip and knee arthroplasties and factors associated with infection

OBJECTIVE

To characterize arthroplasty procedures, calculate the surgical infection rate and identify related risk factors.

METHODS

This was a retrospective cohort study. Data on operations performed between 2010 and 2012 were gathered from documental sources and were analyzed with the aid of statistical software, using Fisher's exact test, Student's t test and the nonparametric Mann-Whitney and Wilcoxon tests.

RESULTS

421 total arthroplasty procedures performed on 346 patients were analyzed, of which 208 were on the knee and 213 on the hip. It was found that 18 patients (4.3%) were infected. Among these, 15 (83.33%) were reoperated and 2 (15.74%) died. The prevalence of infection in primary total hip arthroplasty procedures was 3%; in primary total knee arthroplasty, 6.14%; and in revision of total knee arthroplasty, 3.45%. Staphylococcus aureus was prevalent. The length of the surgical procedure showed a tendency toward being a risk factor (p = 0.067).

CONCLUSION

The prevalence of infection in cases of primary total knee arthroplasty was greater than in other cases. No statistically significant risk factors for infection were identified.

The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty

The aim of the study was to examine the relationship between comorbidities and pain, physical function and health-related quality of life (HRQoL) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A cross-sectional retrospective survey was conducted including 19 specific comorbidities, administered in patients who underwent THA or TKA in the previous 7-22 months in one of 4 hospitals. Outcome measures included pain, physical functioning, and HRQoL. Of the 521 patients (281 THA and 240 TKA) included, 449 (86 %) had ≥1 comorbidities. The most frequently reported comorbidities (>15 %) were severe back pain; neck/shoulder pain; elbow, wrist or hand pain; hypertension; incontinence of urine; hearing impairment; vision impairment; and cancer. Only the prevalence of cancer was significantly different between THA (n = 38; 14 %) and TKA (n = 52; 22 %) (p = 0.01). The associations between a higher number of comorbidities and worse outcomes were stronger in THA than in TKA. In multivariate analyses including all comorbidities with a prevalence of >5 %, in THA dizziness in combination with falling and severe back pain, and in TKA dizziness in combination with falling, vision impairments, and elbow, wrist or hand pain was associated with worse outcomes in most of the analyses. A broad range of specific comorbidities needs to be taken into account with the interpretation of patients' health status after THA and TKA. More research including the ascertainment of comorbidities preoperatively is needed, but it is conceivable that in particular, the presence of dizziness with falling, pain in other joints, and vision impairments should be assessed and treated in order to decrease the chance of an unfavorable outcome.

Clinical applicability of nursing outcomes in the evolution of orthopedic patients with Impaired Physical Mobility

AIM

to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility

METHOD

longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed.

RESULTS

The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035).

CONCLUSION

the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context.