Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature

The adverse effects with ibuprofen after major orthopedic surgeries: A protocol for the PERISAFE randomized clinical trial

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for pain treatment after elective hip and knee arthroplasties. However, evidence regarding the incidence of adverse effects with short-term NSAID treatment following surgery is limited. We, therefore, aim to assess the adverse effects with an eight-day postoperative treatment with ibuprofen after elective hip and knee arthroplasties.

METHODS AND ANALYSIS

PERISAFE is a randomized, placebo-controlled, blinded multicenter trial with 90-day and one-year follow-up. Eligible patients undergoing elective hip or knee arthroplasty are allocated 1:1 to either ibuprofen 400 mg ×3/day or identical placebo ×3/day for eight days after surgery. The primary outcome is a composite of either death, acute myocardial infarction, stroke, pulmonary embolism, deep venous thrombosis, renal failure, major bleeding, re-operation, gastrointestinal ulcer, or readmission within 90 days postoperatively. Secondary outcomes are hospital-free days within 90 days postoperatively, a composite of ibuprofen and opioid-related adverse reactions based on eight-day postoperative diary, and health related quality of life after 90 days postoperatively. A total of 2904 patients are needed to demonstrate a relative risk reduction of 33% in the placebo group, accepting a risk of type I error of 5% and type II error of 20% and a proportion of serious adverse events in the ibuprofen group of 8%. The primary analysis will be in the modified intention-to-treat population.

ETHICS AND DISSEMINATION

The trial is approved by the Danish Medicine Agency and the Research Ethics Committee (EU CT no. 2022-502, 502-32-00). We plan to submit for publication in a major international peer-reviewed journal and present results at scientific meetings.

Comparative assessment of 5-factor modified frailty index and American Society of Anesthesiologists classification for morbidity and mortality prediction in arthroplasty: A prospective observational study

BACKGROUND

Identifying early predictors of postoperative complications is paramount in frail patients. While the American Society of Anaesthesiologists classification is subjective, the 5-factor modified frailty index is simpler and associated with promising results in predicting morbidity and mortality in various surgical specialities.

METHODS

This prospective observational study assessed the comparative utility of 5-factor modified frailty index and American Society of Anaesthesiologists classification in predicting intensive care unit admission and revision surgery in 220 patients following arthroplasty with standardised anaesthesia techniques under the same group of surgeons. The 5-factor modified frailty index and American Society of Anaesthesiologists class were assessed 1 day before surgery, and postoperatively, all the patients were followed up for 30 days.

RESULTS

American Society of Anaesthesiologists and 5-factor modified frailty index had a significant association with postoperative intensive care unit requirements (odds ratio = 7.5, 95% confidence interval 1.3 to 42.4 and odds ratio = 8.3, 95% confidence interval 1.6 to 17.6, respectively). Only the 5-factor modified frailty index was significantly associated (odds ratio = 5.3, 95% confidence interval 1.3 to 9.7) with revision surgery. Patients with the 5-factor modified frailty index value of 3 had the best predictive odds for postoperative intensive care unit admission (odds ratio = 73.6, 95% confidence interval 7.5 to 718.8) and revision of surgery, particularly during total hip replacement (odds ratio = 54, 95% confidence interval 3.3).

CONCLUSION

The 5-factor modified frailty index exhibited a more robust predictive capacity for postoperative intensive care unit requirements and the likelihood of revision surgery, particularly a 5-factor modified frailty index score of 3 in total hip replacement procedures.

Implementation of a "People-Like-Me" Tool for Personalized Rehabilitation After Total Knee Arthroplasty: A Mixed Methods Pilot Study

RATIONALE

While there are numerous tools available to inform if and when to use total knee arthroplasty (TKA), very few tools exist to help guide the recovery period after surgery.

AIMS AND OBJECTIVES

We piloted a decision support tool that promotes a "people-like-me" (PLM) approach to rehabilitation after total knee arthroplasty (TKA). The PLM approach encourages person-centered care by "using historical outcomes data from similar (past) patients as a template of what to expect for a new patient". In this study, we evaluated how successfully the PLM tool was implemented and examined contextual factors that may have influenced its implementation.

METHODS

Two outpatient physical therapy clinics (Clinics A and B) piloted the PLM tool from September 2020 - December 2022. We gathered data related to its implementation from multiple sources including the electronic health record (EHR), the tool itself, and surveys and interviews with patients and clinicians. We used an explanatory sequential mixed methods design to analyze the data overall and separately by each clinic.

RESULTS

Overall, the clinics met most pre-specified implementation targets, but did not use the tool as frequently as intended. Both clinics identified time, technology, and scheduling barriers to using the tool, but Clinic A scored higher in nearly every implementation outcome. Clinic A's success may have been related to its clinicians' higher level of experience, more positive attitudes towards the tool, and more active approach to implementation compared to Clinic B.

CONCLUSIONS

The clinics met most of our implementation targets, but Clinic A experienced more success than Clinic B. Future efforts to implement this PLM tool should (1) engage clinicians as active participants in the implementation process, (2) explore whether incorporating treatment recommendations into the PLM tool and/or using alternative training strategies can enhance its ability to alter clinician behavior, (3) integrate the tool within the EHR to complement existing workflows and mitigate implementation barriers, and (4) include randomized controlled trials that evaluate the tool's effectiveness and scalability across diverse clinical settings.

Multidimensional Analysis of Preoperative Patient-Reported Outcomes Identifies Distinct Phenotypes in Total Knee Arthroplasty: Secondary Analysis of the SHARKS Registry in a Public Hospital Department

Traditional research on total knee arthroplasty (TKA) relies on preoperative patient-reported outcome measures (PROMs) to predict postoperative satisfaction. We aim to identify distinct patient phenotypes among TKA candidates, and investigate their correlations with patient characteristics. Between 2017 and 2021, patients with primary knee cases at a metropolitan public hospital were enrolled in a clinical quality registry. Demographics, clinical data, and the Veterans Rand 12 and Oxford Knee Score were collected. Imputed data were utilized for the primary analysis, employing k-means clustering to identify four phenotypes. Analysis of variance assessed differences in scores between clusters, and nominal logistic regression determined relationships between phenotypes and patient age, sex, body mass index (BMI), and laterality. The sample comprised 389 patients with 450 primary knees. Phenotype 4 (mild symptoms with good mental health) exhibited superior physical function and overall health. In contrast, patients in phenotype 2 (severe symptoms with poor mental health) experienced the most knee pain and health issues. Phenotype 1 (moderate symptoms with good mental health) reported high mental health scores despite knee pain and physical impairment. Patient characteristics significantly correlated with phenotypes; those in the severe symptoms with poor mental health phenotype were more likely to be younger, female, have a higher BMI, and bilateral osteoarthritis (p < 0.05). This multidimensional analysis identified TKA patient phenotypes based on common PROMs, revealing associations with patient demographics. This approach has the potential to inform prognostic models, enhancing clinical decision-making and patient outcomes in joint replacement.

Design features of the rotating head total hip arthroplasty by Weber-Huggler- a forgotten technical solution to reduce wear

Total hip arthroplasty (THA) is a very successful operation. Once the problem of implant fixation was solved with the use of bone cement, the next development steps focused on improving the bearing. Weber, a Swiss surgeon, introduced the first modular heads in THA. His design improved reconstruction of the patients' anatomy using various neck lengths, eased revision as well-fixed stems could be preserved, and also reduced wear due to a cylindrical, rotating connection between the head and neck. The features and results of this exceptional design are reviewed. However, as newer material combinations greatly mitigated the problem of wear and as the dimensions of the cylindrical connection limit range of motion, it was supplanted by the nowadays well-established Morse taper connection, which also is less complex to manufacture. As Weber's design was associated with good long-term results, the technical features of this technical solution should not be forgotten.

Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015-2020

Total hip arthroplasty (THA) is a widely performed surgical procedure in the United States, but disparities in THA outcomes related to hospital-level factors, such as safety-net burden, are underexplored. This study expands on previous research by analyzing multicenter, multistate data from 2015 to 2020 to investigate the impact of hospital safety-net burden-defined as the proportion of services billed to Medicaid and uninsured patients-on THA outcomes. This study is a retrospective analysis using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York, Washington, New Jersey, and North Carolina. The study cohort included 543,814 inpatient primary THA admissions, with patient demographics, comorbidities, and hospital characteristics analyzed across 3 categories of hospital safety-net burden (low, medium, and high). Generalized linear mixed models assessed the association between safety-net burden and in-hospital mortality and postoperative complications, whereas multilevel negative binomial regression evaluated the impact on hospital length of stay. The study findings indicate that patients undergoing THA at hospitals with high safety-net burden had significantly higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.02-1.42), postoperative complications (aOR 1.33, 95% CI 1.20-1.48), and longer hospital stays (adjusted incidence rate ratio 1.15, 95% CI 1.10-1.21) compared with those at low-burden hospitals. These results suggest that hospitals with higher safety-net burden, often serving more vulnerable populations, may have suboptimal perioperative processes and protocols, leading to poorer outcomes. The study underscores the need for targeted interventions to improve THA outcomes in these hospitals.

Complete Blood Cell Count-Based Ratios Identify Total Joint Arthroplasty Patients Likely to Benefit from Perioperative Dexamethasone

BACKGROUND

Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

METHODS

The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

RESULTS

A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

CONCLUSIONS

Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Titanium-Titanium Junctions in the Knee Corrode, Generating Damage Similar to the Hip

BACKGROUND

Previous studies identified corrosion between the modular tibial components of total knee arthroplasty devices. However, gaps persist. Compared to the hip, damage modes that occur within taper junctions in the knee remain poorly understood. In this study, we investigated corrosion on total knee arthroplasty components with titanium-titanium junctions. We asked the following question: under typical in vivo cyclic loading conditions, will the same alloy damage modes from total knee arthroplasty devices resemble those documented in the hip?

METHODS

A total of 50 paired titanium alloy tibial baseplates and stems were collected and semiquantitatively analyzed using Goldberg corrosion scoring. To characterize damage, a subsection of moderately and severely corroded components was sectioned and imaged using scanning electron and digital optical microscopy.

RESULTS

Of the 100 device components, 95% showed visual evidence of corrosion. The initial contact area between the stem and bore generally occurred 3 mm from the stem taper base. Scanning electron microscopy revealed 4 damage modes, including oxide film formation, crevice corrosion, selective dissolution, and pitting.

CONCLUSIONS

Each of the damage modes identified in modular titanium-titanium tibial junctions was previously reported by total hip arthroplasty retrieval studies. Cumulatively, our results suggest that mechanically assisted crevice corrosion promoted this damage in vivo.

The Role of Risk Tolerance in a Patient's Decision to Undergo Total Knee and Hip Arthroplasty

BACKGROUND

A patient's decision-making process to undergo surgery is crucial for surgeons to understand for patient-counseling purposes. Total knee and hip arthroplasty, like any other major surgery, is associated with serious, sometimes life-threatening, complications. Using the results of discrete choice experiments (DCEs), we aimed to understand the relationship between a patient's risk tolerance and choosing to undergo surgery in real life.

METHODS

This is a retrospective study of prospectively collected DCE results for 142 potential knee or hip arthroplasty clinic patients from October 2021 to March 2022. The DCE presented the patient with 2 scenarios, each of which was made up of different combinations of attributes and levels. A hierarchal Bayesian model was used to obtain a risk score that reflected the risk attributes chosen by each patient. Logistic regressions were then used to evaluate the association between a patient's willingness to incur risk and their decision to undergo a total joint arthroplasty.

RESULTS

Of the 142 patients enrolled in the DCE, 89 (62.3%) underwent a total joint arthroplasty. Risk score (odds ratio [OR] = 2.6, 95% confidence interval [CI] 1.1 to 6.6, P = 0.04), men (OR = 2.5, 95% CI 1.1 to 5.9, P = 0.028), and patients who have hip osteoarthritis (OR = 2.4, 95% CI 1.1 to 5.5, P = 0.036) increased the odds of undergoing arthroplasty, whereas physical function of at least 75% at the initial visit (OR = 0.3, 95% CI 0.1 to 0.7, P = 0.004) decreased these odds.

CONCLUSIONS

We found that a patient's willingness to incur risk, lower baseline physical function, and men were all independently associated with undergoing total knee arthroplasty. We believe that these findings prompt much-needed future studies that focus solely on the relationship between patients' inherent risk behavior and surgical and patient-reported outcomes.

Clinical and cost-effectiveness of earlier discharge from acute hospital after total joint arthroplasty

BACKGROUND

Reducing length of stay has been proposed as a key component of policies that aim to meet demand and minimize costs associated with total joint arthroplasty. However, few studies explore shifting of healthcare utilization when length of stay is shortened.

METHODS

This retrospective cohort study examined patients undergoing primary, total hip and knee arthroplasty for osteoarthritis to simulate a policy-level institutional reduction in acute hospital stay by 1 day. Costs, quality of life, and rates of complications, readmission and discharge to inpatient rehabilitation were compared in patients with a three- and four-day length of acute stay. Balance was achieved using overlap-propensity weighting.

RESULTS

In total, 2023 patients were included. Earlier discharge from acute hospital was not associated with a change in odds of 90-day complications (OR: 0.85 [95% CI, 0.58 to 1.27]; P = 0.447), readmissions (OR: 1.11 [95% CI, 0.67 to 1.82]; P = 0.691), and emergency department presentations (OR: 1.07 [95% CI, 0.66 to 1.73]; P = 0.774). Earlier discharge from acute hospital was associated with an increase in odds of discharge to inpatient rehabilitation (OR: 2.16 [95% CI, 1.45 to 3.20]; P < 0.001). No significant differences in costs and quality adjusted life years were observed at one-year. Cost savings during index admission were shifted onto increased costs associated with inpatient rehabilitation.

CONCLUSION

Earlier discharge was not associated with changes in 90-day complications, readmission, or ED presentations. However, an increase in utilization of inpatient rehabilitation was observed, offsetting early cost savings. Patients who were discharged from acute care on day three had no difference in costs compared to those discharged on day four.

Association between multimorbidity and quality of life after hip replacement surgery: analysis of routinely collected patient-reported outcomes

BACKGROUND

Total hip replacement surgery is performed to improve quality of life (QoL). We explored the association between multimorbidity and change in QoL after total hip replacement.

METHODS

Analysis of patients included in the NHS England hip replacement Patient Reported Outcome Measures (PROMs) database with complete preoperative from 3 to 6 months postoperative EQ-5D QoL data from April 2013 to March 2018. Multimorbidity was defined as two or more chronic diseases excluding arthritis. The primary outcome measure was change in QoL using the Pareto Classification of Health Change. We compared QoL change for patients with and without multimorbidity and those with no multimorbidity using multivariable modelling. Data are presented as odds ratio (OR) with 95% confidence interval or n (%).

RESULTS

Of 216,191 patients, we included 178,129 (82.4%) patients with complete data. Most patients 63,327 (35.6%) were 70-79 yr of age, and 98,513 (55.3%) were women. Multimorbidity was present in 38,384 patients (21.6%). QoL improved after surgery for 149,774 (84.1%) patients, remained unchanged for 10,219 (5.7%) patients, and became worse after surgery for 7289 (4.1%) patients. QoL changes were mixed (at least one QoL domain improved and at least one deteriorated) for 10,847 (6.1%) patients. Poor QoL outcomes (unchanged/mixed/worse) were more likely for patients with multimorbidity (OR 1.53 [1.49-1.58]).

CONCLUSIONS

Hip replacement surgery improves QoL. However, patients with multimorbidity are less likely to experience these benefits. Poor QoL outcomes became more frequent as the number of comorbid diseases increased. These data should inform shared decision-making conversations around joint replacement surgery.

How Much Does Prosthetic Joint Infection and Its Successful Treatment Affect Patient-reported Quality of Life?

BACKGROUND

Uncomplicated joint replacement improves pain and other patient-reported outcome measures (PROMs) such as joint function scores and quality-of-life measures. However, the overall impact of periprosthetic joint infection (PJI) and its successful treatment on PROMs is poorly defined. In this study, we describe quality-of-life scores using the 12-item Short Form survey, version 2 (SF-12v2), collected as part of a large, prospective, observational study of PJI.

QUESTIONS/PURPOSES

(1) Do patients with newly diagnosed PJI have lower quality-of-life scores than the general age-matched population? (2) Are lower quality-of-life scores for patients with PJI sustained for ≥ 12 months? (3) What factors are associated with a good functional outcome at 12 months, defined by achieving a physical component summary (PCS) score of > 50 on the SF-12v2 (that is, above the age-adjusted population mean) or an increase of > 8.9 or more from baseline?

METHODS

The PIANO (Prosthetic joint Infection in Australia and New Zealand, Observational study) cohort was a prospective, longitudinal, multicenter cohort study of 783 patients with newly diagnosed PJI recruited across 27 centers between July 2014 and December 2017. All participants were followed for 2 years. SF-12v2 scores were collected at diagnosis (baseline) and 3, 12, and 24 months after diagnosis. Treatment success was defined as being alive with no clinical or microbiological evidence of infection and no ongoing use of antibiotics for the index joint.

RESULTS

After exclusion of 6.6% (52) who had died, 4.2% (33) with PJI of joints other than hips and knees, and those with incomplete data sets (200 [25.5%]), 498 patients had complete SF-12v2 data sets available. At baseline, the median (IQR) PCS score was 37 (30 to 46), which increased to 41 (34 to 49; p < 0.001) at 12 months. Both measures were lower than those for the general age-matched population norm. There was no further improvement in PCS scores between 12 and 24 months. By contrast, the median (IQR) mental component summary score of the SF-12v2 was similar to age-adjusted population norms (48 [37 to 57]) at baseline. Only 40% of patients with PJI achieved a good functional outcome at 12 months. After adjustment for other factors, treatment success of PJI increased the odds of a good functional outcome by 67% (95% CI 11% to 154%; p = 0.02).

CONCLUSION

PJIs have a large effect on the PCS score of the SF-12v2 quality-of-life measure at baseline, which is sustained for at least 2 years. Successful treatment of PJI increases the likelihood of a good functional outcome. These data can be used to set expectations for patients presenting with PJI and can be used to inform future clinical studies in which quality-of-life measures are incorporated into clinical endpoints.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Transition from straight lateral to direct anterior approach in total hip arthroplasty: a retrospective single-centre study

INTRODUCTION

The muscle-sparing direct anterior approach (DAA) for total hip arthroplasty (THA) has gained popularity for reduced postoperative pain and faster rehabilitation. The aim of this study was to evaluate the potential benefits of transitioning from straight lateral approach (SLA) THA to DAA THA, and investigate whether these benefits outweigh potential disadvantages of the DAA learning curve.

METHOD

Patients undergoing surgery between 2015 and 2020 (n = 2275) were categorised into three periods: pre-transition period (2015-2016) utilizing SLA exclusively, transition period (2017-2018) incorporating both SLA and DAA, and post-transition period (2019-2020) employing only DAA. The Hip disability and Osteoarthritis Outcome Score - Physical function Short-form (HOOS-PS) was recorded pre-surgery and one-year post-surgery. Furthermore, complications, blood loss, duration of surgery and length of stay were compared between groups.

RESULTS

A larger improvement in HOOS-PS score was found for DAA in comparison with SLA (37.13 ± 18.62 vs. 32.55 ± 22.83; p < 0.001). Significant improvements were found for the DAA group regarding duration of surgery (70:02 ± 15:54 min vs. 79:47 ± 15:03 min; p < 0,001) and length of stay (1.68 ± 1.80 days vs. 3.39 ± 1.85 days; p < 0,001) compared to the SLA group. Total number of complications was higher for SLA (n = 87 (9.2%)) compared to DAA (n = 77 (6.5%); p = 0.018), with more femoral fractures for SLA (n = 35 (3.7%) vs. n = 6 (0.5%); p < 0.001) whereas more dislocations were found for DAA (n = 24 (2.0)% vs. n = 7 (0.7%); p = 0.017). More specifically, a higher number of dislocations occurred during the DAA transition period when compared to the SLA pre-transition period (n = 12 (2.7%) vs. n = 4 (0.6%); p = 0.008).

CONCLUSIONS

Transitioning from SLA to DAA for THA improves patient-reported outcomes but does not seem to result in a higher overall complication rate. Suggesting the advantages of the DAA outweigh the potential disadvantages of the learning curve.

Variation in Demographics, Hospital, and Patient-Reported Outcomes Following Total Hip Arthroplasty According to Biological Sex

BACKGROUND

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

METHODS

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores.

RESULTS

A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

CONCLUSIONS

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.

Stress, Resilience, Sexual Functioning and Quality of Life in Patients Undergoing Arthroplasty and Arthroscopy

Background

In India, the incidence of orthopaedic conditions is significantly increasing, with 63 million people suffering from various orthopaedic issues, causing considerable distress to patients. This study aims to assess stress, resilience, sexual functioning, and quality of life in participants who underwent arthroplasty and arthroscopy surgery at baseline, one month, and three months.

Method

This comparative study utilised the Perceived Stress Scale (PSS), Connor-Davidson Resilience Scale, Sexual Function Scale, and the WHO Quality of Life Scale.

Results

The comparison between arthroscopy and arthroplasty reveals distinct patterns in stress, resilience, sexual functioning, and quality of life. For both procedures, stress levels were higher at baseline and one-month post-surgery but decreased by three months. Resilience scores improved consistently over time in both groups. However, sexual functioning and quality of life showed different trends: while sexual functioning initially decreased post-arthroscopy but improved by three months, arthroplasty participants generally experienced a more consistent improvement in both sexual functioning and quality of life from baseline through the follow-up periods.

Conclusion

The study showed that stress was significantly higher at baseline and one-month post-surgery. However, the trends in sexual functioning and quality of life differed between the two types of surgery. These findings highlight the need for tailored patient support and interventions based on the type of orthopaedic procedure performed.

Efficacy of Kinesiotaping on Functional Outcomes, Pain, and Edema in the Early Rehabilitation After Total Knee Arthroplasty Surgery: A Randomized Controlled Trial

Background/Objectives: The aim of our study was to verify whether the application of Kinesiotaping in addition to the usual treatment was superior to the usual treatment alone regarding functional outcome, pain, and edema in the first 13 days after total knee arthroplasty (TKA) surgery. Methods: The study sample (n = 71) comprised 42.3% men and the mean age was 68.1 (±9) years. A 1:1 ratio randomization list was used to allocate the patient either to a Kinesiotaping Group (KT) or to a control (CON) group. The KT and CON groups received the same volume of standard post-TKA rehabilitation. KT was additionally treated with lymphatic correction applications of Kinesiotaping (Kinesio® Tex Classic, Mogliano Veneto, Italy) on day 3 (±1) and 7 (±1) post-surgery (two applications during the rehabilitation period). Each application lasted four to five days before removal. KT was removed before the patients' discharge. The main outcome measures were as follows: (1) the circumference at knee level; (2) the VAS for pain; (3) the 10 m Walking Test; (4) the Timed Up and Go Test; (5) the passive knee range of motion; (6) body composition; (7) the Functional Independence Measure; and (8) the Modified Barthel Index. Data were collected at T0 (before surgery), T1 (3 ± 1 days after surgery), T2 (7 ± 1 days after surgery), and T3 (13 ± 1 days after surgery). Results: No inter-group differences were found between KT and CON at T0, T1, T2, and T3. An effect of time was observed for all outcome measures. Conclusions: No superiority of Kinesiotaping was observed compared to the usual rehabilitation treatment.

Accelerometer-based daily physical activity monitoring in patients with postpartum sacroiliac joint dysfunction: a case-control study

Patients with low back pain caused by sacroiliac joint (SIJ) dysfunction have an impaired quality of life, due to reported pain, disability and activity limitations. There is increasing evidence that minimally invasive sacroiliac joint fusion (MISJF) results in improvement in pain, disability and quality of life in these patients. Some studies have reported improvements in daily physical activity following MISJF but based on bias-prone self-reports. Our aim was to provide objective data on daily physical activity in patients with SIJ dysfunction. Daily physical activity in daily life of participants was measured using a triaxial accelerometer for seven consecutive days, before surgery and 3 months after surgery. Recorded daily activities were the daily number of events and total time spent sitting or lying, standing, walking, cycling, high-activity and number of steps and sit-to-stand transfers. The quality of life was assessed by the validated Dutch EQ-5D-5 L-questionnaire. No statistical differences were observed between daily physical activity in patients with SIJ dysfunction before and 3 months after MISJF. As compared to matched controls, high-intensity physical activity was lower in both the pre- and postoperative period (p = 0.007) for patients with SIJ dysfunction. The quality of life improved significantly in patients after MSIJF, from 0.418 to 0.797 (p = 0.021) but did not reach the level of controls (1.000). Daily physical activity in patients with postpartum SIJ dysfunction does not improve 3 months following MISJF, while quality of life does improve significantly. The discrepancy between these two observations is food for new research.

Functional Patient-Reported Outcome Measures After Hip or Knee Arthroplasty: A Systematic Review and Content Analysis Using the International Classification of Functioning, Disability, and Health

OBJECTIVE

This systematic review aimed to identify the existing patient-reported outcome measures (PROMs) used in hip or knee arthroplasty for adults with osteoarthritis and assess their content validity using the modified International Classification of Functioning, Disability, and Health (ICF) core set for osteoarthritis (OA).

METHODS

Four databases were systematically searched to identify disease or joint-specific PROMs evaluating function after hip or knee arthroplasty. Two reviewers independently evaluated the content of PROMs based on established ICF linking rules.

RESULTS

From 449 studies included in this review, 50 PROMs were identified. The mobility chapter of activities and participation was the most common component, followed by the sensory function and pain chapter of body function and structure. The most frequent ICF activity and participation categories were d451 going up and down stairs, d4701 using private motorized transportation, d4104 standing, and d4154 maintaining a standing position. However, 11 ICF categories of the modified OA core set were not captured in any PROMs. This ICF-based content analysis of PROMs revealed that included activity and participation categories vary widely, with little overlap among PROMs. The Knee Injury and Osteoarthritis Outcome Score and the Hip Disability and Osteoarthritis Outcome Score had the most coverage for activity and participation (36.7%).

CONCLUSION

Even though our search identified 50 specific PROMs, there remain gaps in content related to activity and participation coverage. By providing a content analysis of the PROMs used after hip or knee arthroplasty, this study may help clinicians select PROMs based on covered categories and relevant clinical objectives.

Effectiveness of prehabilitation on outcomes following total knee and hip arthroplasty for osteoarthritis: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To quantify the effectiveness of prehabilitation prior to total knee and hip arthroplasty (TKA/THA) for osteoarthritis on postoperative outcomes assessed by self-report and performance-based measures.

METHODS

Embase, MEDLINE, CENTRAL, CINAHL and Scopus (inception-August 2022) were searched for randomized controlled trials. Self-report outcomes were function, health-related quality of life (HRQoL), and pain. Performance-based outcomes were strength, range of motion (ROM), balance, and functional mobility. The RoB 2.0 assessed risk of bias. Random-effects meta-analysis was performed up to 52 weeks after TKA/THA.

RESULTS

High risk of bias was found in 24 of 28 trials. Prehabilitation improved function (SMD = 0.50 [95%CI: 0.23, 0.77]), pain (SMD = 0.44 [95%CI: 0.17, 0.71]), HRQoL (SMD = 0.28 [95%CI: 0.12, 0.43]), strength (SMD = 0.72 [95%CI: 0.47, 0.98]), ROM (SMD = 0.31 [95%CI: 0.02, 0.59]), and functional mobility (SMD = 0.39 [95%CI: 0.05, 0.73]) post-TKA. No significant effect of prehabilitation on balance (SMD = 0.28 [95%CI: -0.11, 0.66]) post-TKA. All outcomes assessed had significant heterogeneity (p < 0.01). There were limited and contradictory trials (n = 2) for THA.

CONCLUSION

High risk of bias and significant heterogeneity observed in our meta-analysis prevent conclusions regarding prehabilitation effectiveness on outcomes up to one year after TKA/THA.

Is early rehabilitation after Total Knee Replacement better with periarticular cocktail of injection or epidural Ropivacaine?

TKA is routinely done orthopaedic procedure done that aims at improving the quality of patients' life by providing pain relief, functional improvement and deformity correction. This study aims to study the efficacy and safety of a Periarticular analgesic cocktail including ropivacaine injection and epidural ropivacaine for early rehabilitation after a total knee replacement.

METHODS

Total of 100 patients divided into two groups, one group received epidural ropivacaine and second group given periarticular cocktail containing ropivacaine. Then postoperatively their pain score comparison using VAS score and their functional status is documented knee society score.

RESULTS

The mean age for the epidural group is 60.28 years, while for the periarticular cocktail group it's 60.88 years. For female patients, 34 (68%) received epidural analgesia, while 24 (48%) received periarticular cocktail. Among male patients, 16 (32%) had epidural analgesia, and 26 (52%) received periarticular cocktail. For pre-operative pain scores, patients receiving Epidural analgesia had a slightly higher mean score of 7.24 compared to those receiving Periarticular Cocktail, who had a mean score of 7.12. Patients in the Epidural group had a higher mean knee flexion of 83.84 degrees compared to the Periarticular Cocktail group, which had a mean flexion of 79.36 degrees. The Knee Society Scores (KSS) for the post-operative scores; The Epidural group had a mean score of 80.16. The Periarticular Cocktail group had a mean score of 88.40.

CONCLUSION

In conclusion, this study supports the periarticular analgesic cocktail over epidural analgesia for pain management and early rehabilitation following TKR.

Modular versus monobloc dual mobility components for primary cementless total hip arthroplasty: a systematic review and meta-analysis of implants' survival, complication rates, clinical and radiographic outcomes

PURPOSE

The dual mobility cup (DMC) reduces the dislocation rates in total hip arthroplasty (THA). DMC systems include anatomical (non-modular or monoblock) (ADM) and modular dual mobility (MDM) components (Stryker Orthopaedics, Mahwah, NJ, USA). This review aims to assess differences between these two types of DMC implants concerning dislocation and revision rates, as well as patient-reported outcomes.

METHODS

This systematic review and meta-analysis of studies reports data from patients undergoing primary THA using MDM and/or ADM implants. Following the PRISMA guidelines, we analyzed articles from Science Direct/Scopus, PubMed, and the Cochrane Database of Systematic Reviews. We compared dislocation rates, revisions for any reason, aseptic loosening, infections, fractures, and functional outcomes between ADM and MDM components.

RESULTS

Eleven studies were considered eligible for further analysis. A total of 3369 patients (mean age = 65.4 years) underwent primary THA, including 3386 DMC implants. The mean follow-up for the MDM and ADM groups was 2.9 years and 3.9 years, respectively. The study revealed one dislocation in the MDM and none in the ADM. By proportion metanalysis, the review did not show statistical differences in all-cause revisions (p = 0.93, [CI [0.01;0.02]) or periprosthetic fractures (p = 0.18, CI [0.01;0.02]).

CONCLUSIONS

MDM and ADM systems, both, represent safe DM options regarding dislocation, all-causes revisions and functional outcomes.

Antibody-antibiotic conjugate targeted therapy for orthopedic implant-associated intracellular S. aureus infections

INTRODUCTION

Treating orthopedic implant-associated infections, especially those caused by Staphylococcus aureus (S. aureus), remains a significant challenge. S. aureus has the ability to invade host cells, enabling it to evade both antibiotics and immune responses during infection, which may result in clinical treatment failures. Therefore, it is critical to identify the host cell type of implant-associated intracellular S. aureus infections and to develop a strategy for highly targeted delivery of antibiotics to the host cells.

OBJECTIVES

Introduced an antibody-antibiotic conjugate (AAC) for the targeted elimination of intracellular S. aureus.

METHODS

The AAC comprises of a human monoclonal antibody (M0662) directly recognizes the surface antigen of S. aureus, Staphylococcus protein A, which is conjugated with vancomycin through cathepsin-sensitive linkers that are cleavable in the proteolytic environment of the intracellular phagolysosome. AAC, vancomycin and vancomycin combined with AAC were used in vitro intracellular infection and mice implant infection models. We then tested the effect of AAC in vivo and in vivo by fluorescence imaging, in vivo imaging, bacterial quantitative analysis and bacterial biofilm imaging.

RESULTS

In vitro, it was observed that AAC captured extracellular S. aureus and co-entered the cells, and subsequently released vancomycin to induce rapid elimination of intracellular S. aureus. In the implant infection model, AAC significantly improved the bactericidal effect of vancomycin. Scanning electron microscopy showed that the application of AAC effectively blocked the formation of bacterial biofilm. Further histochemical and micro-CT analysis showed AAC significantly reduced the level of bone marrow density (BMD) and bone volume fraction (BV/TV) reduction caused by bacterial infection in the distal femur of mice compared to vancomycin treatment alone.

CONCLUSIONS

The application of AAC in an implant infection model showed that it significantly improved the bactericidal effects of vancomycin and effectively blocked the formation of bacterial biofilms, without apparent toxicity to the host.

Influence of Femoral Stem Geometry on Total Hip Replacement: A Comparison of Clinical Outcomes of a Straight and an Anatomical Uncemented Stem

Background/Objectives: There are many aspects that may influence clinical outcomes in a total hip arthroplasty (THA). The influence of femoral stem on the clinical outcome of THA is probably underestimated in the literature. Our work aims to analyze how uncemented stem geometry (straight or anatomical) in THA might affect outcomes in clinical and radiographic terms. Methods: Over a period of 36 months, in a prospective-observational manner, we collected the results of THA secondary to osteoarthritis (OA) that met the inclusion criteria with the only variable being the straight or anatomical stem design in a single manufacturer. A total of 84 patients were selected and divided into two groups: group A, treated with straight stem (44 patients), and group B, treated with anatomical stem (40 patients). The assessment clinical tools were Harris Hip Score (HHS), Visual Analogue Scale (VAS), and Short Form Health Survey-36 (SF-36). Follow-up controls were at 6 months (T0), 12 months (T1), 24 months (T2), and 36 months (T3). Results: No statistically significant differences emerged between the two groups under analysis with VAS, SF-36, and HHS. At follow-up controls, eight patients (group A) and four patients (group B) showed anterior thigh pain. At T1, there were radiographic signs of aseptic loosening in two cases (group A) and one case (group B). In group A there were two cases of iatrogenic fracture, two cases of dislocation, one case of infection, and two cases of heterotopic ossification. Conclusions: The anatomical stem compared to the straight stem showed lower complication rates outcomes; the anatomical uncemented stem could be considered as a preferred first choice in THA compared to the straight stem.

Comparison Between Total Hip and Knee Arthroplasty on Short-Term Performance-Based Outcomes and Factors Associated with the Improvement of Gait Function During Post-Acute Inpatient Rehabilitation

Background: Data on the differences in functional recovery between inpatient rehabilitation for total hip arthroplasty (THA) and total knee arthroplasty (TKA) are lacking, and the factors influencing the improvement of short-term functional mobility remain unknown. In this study, we compared the short-term functional outcomes of both procedures and identified early postoperative predictors of physical function gain during post-acute rehabilitation. Methods: A total of 435 patients who underwent THA and TKA were included. The main outcomes were knee extension strength, the motor component of the Functional Independence Measure, Numerical Rating Scale, 10 Meter Walk Test, Timed Up and Go (TUG) test, and the Berg Balance Scale. The recovery process and rehabilitation outcomes were compared between patients with THA and TKA. Additionally, predictors related to physical performance improvement were examined for each procedure. Results: Patients with THA and TKA achieved significant short-term functional recovery after multidisciplinary rehabilitation (time; p < 0.001). However, the pain score was higher at discharge in patients with TKA (p < 0.001). Age (β: -0.264, p = 0.009) and TUG test (β: -0.884, p < 0.001) in THA, and non-operated knee extension strength (β: 0.234, p = 0.016) and TUG test (β: -0.783, p < 0.001) in TKA were significant early postoperative predictors of functional mobility. Conclusions: Multidisciplinary rehabilitation was beneficial for functional improvement in patients with THA and TKA despite persistent pain at discharge after TKA. Baseline functional levels in both groups and non-operated knee extension strength in TKA can be useful performance-based predictors of short-term gait function improvement.

Trends in Preoperative Outcome Measures From 2013 to 2021 in Patients Undergoing Primary Total Joint Arthroplasty

INTRODUCTION

The prevalence of total joint arthroplasty (TJA) continues to increase exponentially. Patient-reported outcome measures (PROMs) are used to define clinical and quality-of-life improvement and for reimbursement. Temporal trends of preoperative PROMs and specifically how COVID-19 has affected these PROMs is lacking. This study evaluated preoperative PROMs over time, whether medical factors affected preoperative PROMs, and what correlations the COVID-19 pandemic had with these trends in PROMs.

METHODS

A total of 3,014 patients who underwent primary total hip total hip arthroplasty or total knee arthroplasty from 2013 to 2021 were retrospectively reviewed for covariates and preoperative PROMs. Commonly reported preoperative PROMs were evaluated in univariate and multivariate models.

RESULTS

Preoperative activity level steadily increased from 2015 to 2021 for THAs and steadily increased from 2015 to 2019 for TKAs, followed by a decrease in 2020. Preoperative KOOS JR scores increased from 2016 to 2019 and then decreased in 2020 and 2021. Preoperative knee pain with level walking and climbing stairs steadily increased from 2013 to 2019, with additional increases in 2020. The COVID-19 era was significantly associated with higher activity levels for THAs, higher levels of pain with level walking, and lower KOOS JR scores. Preoperative PROM scores demonstrated correlations with postoperative PROM scores, which differed from that during the COVID era (rho range 0.105 to 0.391) at a mean of 2.0 years postoperatively.

DISCUSSION

Surgical delays because of COVID-19 were associated with increased preoperative disability as evidenced by lower activity levels. Aside from this pandemic era, patient activity levels increased over time, indicating that modern TJA patients are more active preoperatively and likely to demand higher levels of function after surgery. Additional studies should evaluate the clinical effect of these statistically significant findings. Providers should consider the trends in preoperative PROMs over time when counseling patients on expectations after TJA.

Cost-Effectiveness of GaitSmart and an Artificial Intelligence Solution for Rehabilitation of Patients Undergoing Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) in Older Population in the United Kingdom

BACKGROUND

GaitSmart (GS) is a sensor-based digital medical device that can be used with the integrated app vGym to provide a personalised rehabilitation programme for older people undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study aimed to determine whether the GS intervention used in the rehabilitation of older people undergoing THA or TKA is potentially cost-effective compared to the current standard of care (SoC).

METHODS

Decision-analytic modelling was conducted to estimate the cost-effectiveness over a seventeen-week time horizon from an NHS perspective. UK clinical and cost data from the GaitSmart randomised clinical trial was used to obtain the input parameters, and a sensitivity analysis was performed to address uncertainties.

RESULTS

Over a seventeen-week time horizon, GS incurred cost savings of GBP 450.56 and a 0.02 gain in quality-adjusted life years (QALYs) compared to the SoC. These results indicate that GS is the dominant intervention because the device demonstrated greater effectiveness and lower costs. Probabilistic sensitivity analyses confirm the robustness of our results.

CONCLUSIONS

GS appears to offer short-term efficiency benefits and demonstrates cost-effectiveness for the improvement in gait in people undergoing THA or TKA, compared to the SoC.

Establishing a Per-Hour Rate for Early-Career Adult Reconstruction Surgeons Performing Medicare Primary Total Joint Arthroplasty

Background

There is a paucity of data regarding compensation for early-career adult reconstruction surgeons. This study aims to quantify the time throughout the full episode of care for a Medicare primary total hip/knee arthroplasty and convert to per-hour pay for early-career arthroplasty surgeons at various geographic locations and practice settings. Using Center for Medicare and Medicaid Services data, this study also compares the compensation of early-career vs established total joint arthroplasty (TJA) surgeons.

Methods

Between January 2022 and January 2023, 3 early-career surgeons in 3 different locations collected prospective data on time spent in patient care during the global period following primary TJAs (pTJAs). A weighted average time spent per pTJA during global period was calculated with the 2024 work relative value unit and conversion factor to establish a per-hour rate. This rate was compared to the compensation rates of other healthcare-related fields and established TJA surgeons using Relative Value Scale Update Committee (RUC) values.

Results

A total of 334 pTJAs (148 hips and 186 knees) were performed among 3 surgeons, and per-hour rates of $87.62 and $87.70 were found, respectively. These are less than hospital/healthcare system/health insurance/med tech CEOs, lawyers, dentists, and travel nurses. Early-career TJA surgeons were found to take 7.98%-8.68% longer than RUC standard times for a TJA episode of care.

Conclusions

This study quantifies the per-hour compensation of early-career arthroplasty surgeons, who earn lower compensation rates to travel nurses and take longer than Center for Medicare and Medicaid Services RUC times for pTJAs. Given the increasing demand for pTJAs, decreasing reimbursement rates, and concern over burnout, access to quality pTJA care for patients is concerning.

A Readmission Risk Assessment Tool Is Not Predictive of 90-Day Readmission After Total Joint Arthroplasty at an Urban Tertiary Referral Hospital

INTRODUCTION

Readmission within 90 days of total joint arthroplasty (TJA) via an emergency department (ED) encounter represents a significant economic burden to the healthcare system. We aimed to determine the utility of a previously described readmission risk assessment tool (RRAT) in predicting readmission after presentation to the ED within 90 days of primary TJA.

METHODS

At a single academic tertiary referral medical center, a retrospective chart review was used to collect demographic data, surgery type, medical history, reason for presentation in the ED, and ED disposition for the 1,576 patients who underwent TJA between April 1, 2016, and December 31, 2018. The RRAT score of patients was calculated and compared between patients who were discharged home versus readmitted to inpatient care.

RESULTS

We identified 244 patients (328 encounters) who presented to the ED within 90 days of primary TJA, resulting in a 3.1% readmission rate. No statistical difference was found between the RRAT scores of readmitted and discharged patients (p=0.24). The most common reason for presentation to the ED for discharged patients was surgical site pain compared to medical concerns (cardiac, hematological, and renal concerns) in the readmitted group.

CONCLUSIONS

Although the RRAT score alone is not predictive of readmission within 90 days of TJA, the reason for presentation to the ED between discharged and readmitted patients does differ. These results present an opportunity for orthopedic surgery providers to discuss with other providers ways to optimize postoperative pain management and decrease readmissions. This study underscores the need for improved postoperative pain and chronic condition management to reduce ED visits and readmissions and highlights the necessity for larger, multi-center studies to better assess the RRAT score's predictive value.

Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review

OBJECTIVE

To systematically review, summarize and appraise evidence on the factors determining quality of life (QoL) after total knee arthroplasty (TKA) in individuals with knee osteoarthritis.

METHODS

We searched six databases (PubMed, Scopus, Web of Science, CINAHL, EMBASE, and ProQuest) using appropriate search terms to identify the relevant literature published on the factors determining QoL following TKA. Two reviewers independently performed the study screening and study selection. A third reviewer was consulted in case of any disagreement. The methodological quality of the included studies was assessed using the Modified Downs and Black Index checklist. This review was registered in PROSPERO (CRD42022352887) and reported according to the PRISMA checklist.

RESULTS

We identified a total of 8517 studies, 29 of which were included. Advanced age; female sex; increased body mass index (BMI); the presence of comorbidities such as diabetes; contralateral knee pain; poor preoperative status; psychological and pain-related factors such as the presence of pain catastrophizing; central sensitization; kinesiophobia; anxiety; depression; chronic pain; psychological distress; low level of optimism; and reduced patient satisfaction were used to determine post-TKA QoL scores. High BMI and depression were the most common factors evaluated in these studies. Overall, the methodological quality of the included studies varied from high to low.

CONCLUSION

After TKA, the overall QoL score improved. However, there are a few physical, behavioral, and psychological factors that influence QoL. Identifying these factors could aid clinicians and health professionals in treating and rehabilitating patients by helping them improve patient prognosis after TKA.

Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch

BACKGROUND

Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center.

METHODS

All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD.

RESULTS

Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830).

CONCLUSIONS

With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Varus knee osteoarthritis with ankle osteoarthritis demonstrates greater hindfoot inversion and larger ankle inversion loading during gait following total knee arthroplasty compared to varus knee osteoarthritis alone

PURPOSE

Although patients with varus knee osteoarthritis (KOA) and concurrent ankle osteoarthritis (AOA) may experience increased ankle joint pain after total knee arthroplasty (TKA), the underlying mechanism remains unclear. This study aimed to investigate the effects of concurrent AOA on ankle and hindfoot alignment, frontal plane ankle and hindfoot biomechanics during gait following TKA and the clinical outcomes.

METHODS

Twenty-four patients with varus KOA who underwent TKA were included in this retrospective cohort study. Patients were categorized into two groups: with and without AOA. Radiographic evaluations of lower-limb, ankle and hindfoot alignment, and knee and ankle clinical outcomes were conducted preoperatively and 6 months postoperatively. In addition, gait analyses were performed to investigate knee, ankle and hindfoot kinematics and kinetics. Each data was compared between patients with and without AOA.

RESULTS

Concomitant AOA was found in eight ankles. The AOA group exhibited greater postoperative hindfoot varus and increased postoperative ankle pain than the non-AOA group. Gait analysis showed no significant differences in knee varus alignment or tibial tilt after TKA between the groups. However, the AOA group demonstrated significantly greater hindfoot inversion and larger ankle inversion loading.

CONCLUSION

One third of patients who underwent TKA had concurrent AOA associated with hindfoot varus. Despite achieving proper coronal knee alignment postoperatively, these patients experienced greater hindfoot and ankle joint inversion load during gait. Surgeons should consider the inability to evert the hindfoot and the possibility of increased ankle joint pain when planning and performing TKA.

LEVEL OF EVIDENCE

Level III.

Evaluation of the Effectiveness of Canadian Cardiovascular Society Guidelines in Minimizing Cardiac Events After Total Hip Arthroplasty

BACKGROUND

The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA.

METHODS

Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines.

RESULTS

The study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol.

CONCLUSIONS

The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.

Geographical Differences in Surgeon Reimbursement, Volume, and Patient Characteristics in Primary Total Hip Arthroplasty

BACKGROUND

The purpose of this study was to evaluate changes in regional and national variations in reimbursement to arthroplasty surgeons, procedural volumes, and patient populations for total hip arthroplasty (THA) from 2013 to 2021.

METHODS

The Medicare Physician and Other Practitioners database was queried for all billing episodes of primary THA for each year between 2013 and 2021. Inflation-adjusted surgeon reimbursement, procedural volume, physician address, and patient characteristics were extracted for each year. Data were stratified geographically based on the United States Census regions and rural-urban commuting codes. Kruskal-Wallis and multivariable regressions were utilized.

RESULTS

Between 2013 and 2021, the overall THA volume and THAs per surgeon increased at the highest rate in the West (+48.2%, +20.2%). A decline in surgeon reimbursement was seen in all regions, most notably in the Midwest (-20.3%). Between 2013 and 2021, the average number of Medicare beneficiaries per surgeon declined by 12.6%, while the average number of services performed per beneficiary increased by 18.2%. In 2021, average surgeon reimbursement was the highest in the Northeast ($1,081.15) and the lowest in the Midwest ($988.03) (P < .001). Metropolitan and rural areas had greater reimbursement than micropolitan and small towns (P < .001). Patient age, race, sex, Medicaid eligibility, and comorbidity profiles differ between regions. Increased patient comorbidities, when controlling for patient characteristics, were associated with lower reimbursement in the Northeast and West (P < .01).

CONCLUSIONS

Total hip arthroplasty (THA) volume and reimbursement differ between US regions, with the Midwest exhibiting the lowest increase in volume and greatest decline in reimbursement throughout the study period. Alternatively, the West had the greatest increase in THAs per surgeon. Patient comorbidity profiles differ between regions, and increased patient comorbidity is associated with decreased reimbursement in the Northeast and the West. This information is important for surgeons and policymakers as payment models regarding reimbursement for arthroplasty continue to evolve.

Comparative Study of Alternative Methods for Measuring Leg Length Discrepancy after Robot-Assisted Total Hip Arthroplasty

BACKGROUND

Our study addresses the lack of consensus on measuring leg length discrepancy (LLD) after total hip arthroplasty (THA). We will assess the inter-observer variability and correlation between the five most commonly used LLD methods and investigate the use of trigonometric principles in overcoming the limitations of current techniques.

METHODS

LLD was measured on postoperative AP pelvic radiographs using five conventional methods. CT images created a 3D computer model of the pelvis and femur. The resulting models were projected onto a 2D, used to measure LLD by the five methods. The measurements were evaluated via Taguchi analysis, a statistical method identifying the process's most influential factors. The approach was used to assess the new trigonometric method.

RESULTS

Conventional methods demonstrated poor correlation. Methods referenced to the centers of the femoral heads were insensitive to LLD originating outside the acetabular cup. Methods referencing either the inter-ischial line or the inter-obturator foramina to the lesser trochanter were sensitive to acetabular and femoral components. Trigonometry-based measurements showed a higher correlation.

CONCLUSIONS

Our results underscore clinicians' need to specify the methods used to assess LLD. Applying trigonometric principles was shown to be accurate and reliable, but it was contingent on proper radiographic alignment.

A comparison of the clinical efficacy of total hip arthroplasty via direct anterior approach and posterior approach: A meta-analysis

BACKGROUND

The approach of total hip arthroplasty (THA) has long been controversial, and many studies have compared different approaches. However, there is still a lack of consistent conclusions and comprehensive, systematic comparisons and evaluations.

METHODS

This study retrieved 7 databases: PubMed, Web of Science, Embase, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and Wanfang Database. The search time ranged from the establishment of each database to November 1, 2023. Data analysis was performed using Review Manager 5.4, and outcome was presented as the weighed mean difference for continuous data and risk/odds ratio for dichotomous data. We used the Mantel-Haneszel method and random effects model to obtain the overall effects of the differences in the impact of 2 surgical methods on clinical outcomes in all included studies.

RESULTS

A total of 33 articles were included in this study, including 14478 participants, 4911 participants in DAA group and 9567 participants in PA group. The visual analogue scale scores of the DAA group at 1 day and 2 days after THA were significantly lower than those of the PA group (mean difference [MD] = -0.56, 95% confidence interval [CI]: -0.83 to -0.30, P < .01) at 1 day and (MD = -0.67, 95% CI: -1.16 to -0.17, P = .01) at 2 days. The risk of intraoperative fracture (odds ratio = 2.18, 95% CI: 1.11-4.29, P = .05) and lateral femoral nerve injury (risk ratio = 7.84, 95% CI: 1.69-36.42, P < .01) in the DAA group was significantly higher than that of the PA group. The number of prostheses in the Lewinnek safe zone of the DAA group was significantly higher than that of the PA group (risk ratio = 1.13, 95% CI: 1.00-1.27, P = .05). The results showed no significant difference between the DAA group and the PA group in the time to stop using walking aids, dislocation rate, groin pain, incision complications, heterotopic ossification, intraoperative blood loss, and acetabular anterior (P > .05).

CONCLUSION

Compared with the PA group, patients in the DAA group showed more ideal anatomical and imaging results, shorter hospital stay, and showing advantages in postoperative pain, but with a higher incidence of intraoperative complications.

Efficacy analysis of clinical serological indicators in the diagnosis of postoperative periprosthetic joint infection in patients with rheumatoid arthritis or osteoarthritis

PURPOSE

To investigate the incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA) or osteoarthritis (OA) after primary joint arthroplasty; to analyze the optimal cut-off values of clinical serum markers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer for the diagnosis of PJI in RA patients; and to explore their diagnostic efficacy and clinical significance.

METHODS

Clinical data of 15,702 patients with RA (578) or OA (15,124) who underwent total joint arthroplasty from 2013 to 2021 were retrospectively analyzed. Serum CRP, ESR, and D-dimer were recorded for each patient, and subject characteristic curves were used to determine the optimal threshold values of CRP, ESR, and D-dimer for RA-PJI and OA-PJI and to compare the areas under the curves to assess the diagnostic efficacy of the optimal threshold values of serologic indices for RA-PJI.

RESULTS

The five year incidence of PJI was 6.92% in RA patients and 0.67% in OA patients. The optimal thresholds of CRP, ESR, and D-dimer for the diagnosis of RA-PJI were respectively 13.85 mg/L, 33.02 mm/h, and 796.50 ng/mL. The sensitivities of the optimal thresholds were respectively 67.6%, 62.2%, and 56.8%, and the specificities were 74.7%, 60.4%, and 74.4%.

CONCLUSION

RA patients have a higher incidence of PJI than OA patients. The optimal thresholds for CRP, ESR, and d-dimer for the diagnosis of PJI were higher in RA patients than in OA patients, but the sensitivity and specificity of the diagnosis were not as good as in OA patients.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BACKGROUND

Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies.

METHODS

All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years).

RESULTS

There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs.

CONCLUSIONS

The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

The Trend of Medicare Reimbursement for Total Joint Arthroplasty: Using Mathematical Models to Predict Possible Per-Hour Rate Out to 2030

Background

While multiple studies have assessed the trends of Medicare reimbursement for orthopedic total joint arthroplasty (TJA) surgeries, none have forecasted reimbursement in relatable per-hour figures. The purposes of this study are to examine trends of reimbursement for primary and revision TJA and translate forecasted primary TJA reimbursement to relatable per-hour compensation.

Methods

The Center for Medicare and Medicaid Services reimbursement data from 1992 to 2024 were used to create a historical view of reimbursement for primary and revision TJA. All monetary values were converted to 2023 USD to account for inflation. Polynomial and linear forecast equations were used to predict the future of the TJA reimbursement to 2030. Relative Value Scale Update Committee standard times for procedures were used with the forecasts to establish per-hour rates.

Results

Total reimbursement for primary total hip arthroplasty/total knee arthroplasty is forecasted to decrease 85.36%/86.14% by 2030. Using prior trends in reimbursement, TJA procedures are predicted to reimburse at or less than $100.00 2023 USD per Medicare case by 2030. Moreover, TJA surgeons are forecasted to earn $13.93/h per primary total hip arthroplasty and $14.97/h per primary total knee arthroplasty by 2030.

Conclusions

This study highlights the concerning trends for both primary and revision arthroplasties as TJA surgeons are on a path to earn below minimum wage for primary TJAs by 2030. Mathematical models forecast a bleak future for orthopedic TJA reimbursement. This downward trajectory poses a risk to access and quality of care.

Do octogenarian patients undergoing total knee replacement return to physical activity?

BACKGROUND AND OBJECTIVES

It has been shown that total knee replacement improves functional capacity and physical activity; however, the influence of age remains unclear. The objective is evaluate the pre and postoperative physical activity measured with the Knee Society Score (KSS) score and the Tegner score.

MATERIALS AND METHODS

A retrospective cohort analysis was conducted on patients who underwent total knee replacement (TKR) between January 2016 and December 2019 at our institution. Demographic variables (age, sex, and body mass index), activities of daily living, age-adjusted Charlson Comorbidity Index, American Society of Anesthesiologists score, the Knee Society Score (KSS) in its clinical (KSSc) and functional (KSSf) subscales, the Tegner functional scale, activity variables from the 2011 KSS version, and pain assessment using the visual analog scale were collected. Differences in these variables were analyzed between two age groups: group A (between 65 and 79 years old) and group B (80 years or older).

RESULTS

A total of 450 patients were evaluated (group A=245, group B=167). Group A showed a Tegner improvement of 1.19 (95% CI: 1.06-1.31), whereas group B averaged 0.61 (95% CI: 0.43-0.80) (P<.001). Age >80 was an independent risk factor for less Tegner improvement. In KSSc, group A improved by 43 points (95% CI: 40.82-46.14), while group B showed a greater increase of 53 points (95% CI: 49.74-57.80). Adjusted for confounders, those>80 showed significantly higher KSSc improvement (12.8 points). For KSSf, group A improved by 33.91 points (95% CI: 31.07-36.75), and group B by 15.57 points (95% CI: 11.78-19.35). Adjusted for confounders, patients >80 had less improvement than those <80 (19 points).

CONCLUSIONS

Patients who underwent TKR experienced improvements in physical and functional activity parameters. While these improvements were seen in the entire population, they were most notable in patients younger than 80 years.

Mendelian randomization of stroke risk after total hip and knee replacements

Objective

Previous epidemiological studies have indicated an increased risk of neurovascular diseases in patients following total hip and knee replacements. However, definitive conclusions regarding the increased risk of stroke post-replacement remain elusive. Therefore, we conducted a two-sample Mendelian randomization study to investigate the causal relationship between total hip and knee replacements and stroke.

Methods

We utilized summary data from publicly available genome-wide association studies (GWAS). Data concerning total hip replacements (THR, N = 319,037) and total knee replacements (TKR, N = 252,041) were sourced from the Genetics of Osteoarthritis (GO) Consortium. Stroke-related data were obtained from the International Stroke Genetics Consortium, encompassing any stroke (AS), any ischemic stroke (AIS), large vessel ischemic stroke (LV-IS), cardioembolic ischemic stroke (CE-IS), and small vessel ischemic stroke (SV-IS). Our primary causal inference method was the inverse variance weighted (IVW) approach, supplemented by weighted median and MR-Egger regression as secondary inference methods. We utilized the MR-PRESSO global test for outlier detection, Cochran's Q statistic to assess heterogeneity, and assessed the multiplicity and stability of our findings using p-values from MR-PRESSO and MR-Egger regressions, and the leave-one-out method, respectively.

Results

We identified significant genetic associations between THR and both AS (IVW p = 0.0001, OR = 1.08, 95% CI = 1.04-1.12) and AIS (IVW p = 0.0016, OR = 1.07, 95% CI = 1.03-1.12). Significant associations were also observed between TKR and AS (IVW p = 0.0002, OR = 1.08, 95% CI = 1.04-1.12), as well as AIS (IVW p = 0.0005, OR = 1.15, 95% CI = 1.06-1.24).

Conclusion

Our findings genetically support an increased risk of stroke following total hip and knee replacements. However, further studies are necessary to elucidate the specific mechanisms underlying stroke episodes post-replacement.

A Pilot Study on the Efficacy of an App-Based Rehabilitation Counselling Program after Total Knee Arthroplasty

The aim of this study was to determine the effects of a novel app-based rehabilitation counselling program in patients recovering from total knee arthroplasty. In the app-based rehabilitation counselling program, a counselor provides one-on-one rehabilitation exercises and management-focused psychological counselling after total knee arthroplasty (TKA). This study included 42 patients, who were divided into three groups of 14 patients each: Group A, whose rehabilitation training was based on a guideline leaflet; Group B, whose rehabilitation was based on the app-based rehabilitation counselling program; and Group C, whose rehabilitation training was based on continuous passive motion combined with the app-based rehabilitation counselling program. To determine the effects of rehabilitation, the isokinetic knee muscle strength and knee joint range of motion were measured in addition to knee function tests such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analogue scale (VAS) for pain at two and three months after rehabilitation. The comparison of the means of the three groups was analyzed using one-way analysis of variance (ANOVA), with Group C showing significant variance in isokinetic knee muscle strength (p < 0.05), passive ROM (p < 0.01), and WOMAC (p < 0.05) after three months. As a result, this study confirmed the positive potential of the app-based rehabilitation counselling program.

In Vivo Kinematic Analysis of Mobile-Bearing Unicompartmental Knee Arthroplasty during High Flexion Activities

Mobile-bearing (MB) unicompartmental knee arthroplasty (UKA) has high conformity between the femoral articular surface and the meniscal bearing; therefore, the surface and subsurface contact stress is reduced. Additionally, the survival rate is high. However, the in vivo kinematics of MB UKA knees during high-flexion activities of daily living remain unknown. The aim of this study was to investigate in vivo the three-dimensional kinematics of MB UKA knees during high-flexion activities of daily living. A total of 17 knees of 17 patients who could achieve kneeling after MB UKA were examined. Under fluoroscopy, each patient performed squatting and kneeling motions. To estimate the spatial position and orientation of the knee, a two-dimensional/three-dimensional registration technique was used. We evaluated the femoral rotation and varus-valgus angle relative to the tibia and the anteroposterior translation of the medial sulcus (medial side) and lateral epicondyle (lateral side) of the femur on the plane perpendicular to the tibial mechanical axis in each flexion angle. From 130° to 140° of flexion, the femoral external rotation during squatting was significantly smaller than that during kneeling. Additionally, the medial side of the femur during squatting was significantly more posteriorly located compared with that during kneeling. There was no significant difference between squatting and kneeling in terms of the lateral side of the femur and the varus-valgus position in each flexion angle. At high flexion angle, the kinematics of MB UKA knees may differ depending on the performance.

The Subjective Hip Value is a Valid, Reliable, and Responsive Instrument for Assessing Hip Function in Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures are essential tools in clinical decision-making and research. Multi-item scores like the modified Harris Hip Score (mHHS) are time-consuming to collect and evaluate. The subjective hip value (SHV), as a single-item value, assesses hip function with one question: "What is the overall percent value of your hip if a completely normal hip represents 100%?". The aims of our study were to assess the psychometric properties, and thus validity, reliability, and responsiveness; and to define the minimal clinically important difference (MCID) of the SHV in patients undergoing total hip arthroplasty.

METHODS

A total of 137 consecutive patients who underwent primary total hip arthroplasty between June 2020 and August 2021 were prospectively enrolled. A SHV and mHHS were collected preoperatively and at follow-ups (6 weeks, 3 months, 6 months, and 1 year). Validity, reliability, responsiveness, MCID, and floor/ceiling effects were evaluated.

RESULTS

There was a significant correlation between SHV and mHHS (P = .001) preoperatively (rs = 0.532), 6 weeks (rs = 0.649), 3 months (rs = 0.765), 6 months (rs = 0.854), and after 1 year (rs = 0.879). Test-retest reliability (rs = 0.74; P = .001) and responsiveness (rs = 0.24; P = .007) showed significant correlations. The MCID for SHV was 10.06%. Floor- and ceiling-effects were comparable to the mHHS.

CONCLUSIONS

The SHV is a valid, reliable, and responsive single-item score for the assessment of hip joint function in arthroplasty patients. It can detect clinically relevant changes in joint function and is easy to collect and interpret, which justifies its implementation in clinical practice.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty

BACKGROUND

A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD.

METHODS

A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression.

RESULTS

Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older.

CONCLUSIONS

The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates.

LEVEL OF EVIDENCE

III.

Impact of implant design on the Forgotten Joint Score: a retrospective study comparing two contemporary knee designs

This retrospective study was designed to assess two fixed bearing total knee design concepts and their clinical outcomes, particularly in Forgotten Joint Score-12 (FJS-12). Patients were assessed clinically using the Knee Society Score (KSS). Participants completed an FJS-12 and a short form of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PS). A total of 216 knees -76 with Genesis II and 150 with Vanguard total knee arthroplasties - were included. Patients in the Vanguard group had significantly better postoperative FJS-12 scores (by 10.1 points, p = 0.019). Differences in KSS subscores also reached the level of statistical significance. KOOS-PS did not differ significantly. Statistically significant differences between the two knee designs on FJS-12, KS and FS assessments were revealed, but overall, these differences may not reach the threshold of clinical significance.

Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is commonly performed for the treatment of knee osteoarthritis (KOA). Poor satisfaction continues to be seen after TKA. Whilst reasons for poor patient satisfaction are multifactorial, there is a strong correlation with persistent pain following TKA. Studies have shown an association between local and remote mechanical hypersensitivity, measured using pressure pain thresholds (PPTs), and severity of knee osteoarthritis and functional status. We aimed to determine if the pre-operative PPTs were associated with patient satisfaction following TKA.

Methods

A prospective longitudinal study of 77 individuals was undertaken. Regression modelling assessed the relationship between Patient Satisfaction using the Knee Society Score (satisfaction subscale) following TKA for KOA, and PPTs recorded pre-operatively locally and remote to the affected knee, while accounting for potentially confounding patient demographic and psychosocial factors.

Results

Lower PPTs (indicating increased mechanical hypersensitivity) locally and remote to the operative knee were modestly associated with lower patient satisfaction in the short-term (six weeks) following TKA (β 0.25-0.28, adjR2 = 0.14-0.15), independent of demographic or psychosocial influences. However, this relationship progressively diminished in the intermediate and long-term post TKA.

Conclusion

While pre-operative PPT measures may provide some foresight to patient satisfaction post TKA in the short term, these measures appear to provide little insight to patient satisfaction in the intermediate and longer term.

Improvement and prognosis of anxiety and depression after total knee arthroplasty

This study aims to analyze the improvement and prognosis of anxiety and depression in patients with knee osteoarthritis after total knee arthroplasty. A retrospective questionnaire survey was conducted on 180 patients with knee osteoarthritis who underwent total knee arthroplasty. The questionnaire consisted of a general information questionnaire, the Zung Self-Rating Anxiety Scale (SAS) for anxiety, the Zung Self-Rating Depression Scale (SDS) for depression, the Visual Analog Scale (VAS), the Pittsburgh sleep quality Index (PSQI), and the American Knee Society Scores (AKSS). The same questionnaires were administered preoperatively and at 3, 6 and 12 months postoperatively, and the results were statistically analyzed. The prevalence of anxiety in preoperative knee osteoarthritis patients was 29.2% and the prevalence of depression was 37.5%. At 3, 6, and 12 months after total knee arthroplasty, anxiety and depression, pain levels, sleep disturbances, and functional status of the knee were significantly improved in patients with knee osteoarthritis compared with the preoperative period (all P<0.05). Patients with knee osteoarthritis have significant anxiety and depression before surgery, and total knee arthroplasty can significantly improve their anxiety, depression and prognosis, and should be performed as early as possible in patients with knee osteoarthritis.

Bilateral simultaneous hip and knee replacement: an epidemiological nationwide study from 2001 to 2016

BACKGROUND

Several studies have compared the pros and cons of simultaneous bilateral versus staged bilateral hip and knee replacement but the outcomes of these two surgical options remains a matter of controversy. This study aimed to evaluate demographic features, incidence and hospitalization rates of bilateral one stage total hip and knee arthroplasty in Italy.

METHODS

The Italian Ministry of Health's National Hospital Discharge Reports (SDO) were used to gather data. This study referred to the adult population (+ 20 years of age) from 2001 to 2015 for hip arthroplasty and from 2001 to 2016 for knee arthroplasty.

RESULTS

Overall, 1,544 bilateral simultaneous hip replacement were carried out. The incidence rate was 0.21 cases per 100,000 adult Italian residents. Male/female ratio was 1.1. The average days of hospital stay was 11.7 ± 11.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, pelvic region and thigh (ICD code: 715.15). 2,851 bilateral simultaneous knee replacement were carried out. The incidence rate was 0.37 cases per 100,000 adult Italian residents. Male/female ratio was 0.6. The average days of hospital stay was 7.7 ± 5.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, lower leg (ICD code: 715.16).

CONCLUSIONS

The burden of hip and knee osteoarthrosis as a leading cause of bilateral joint replacement is significant in Italy. The national registers' longitudinal analysis may provide data for establishing international guidelines regarding the appropriate indications for one stage bilateral simultaneous hip or knee replacement versus two stage.

Longitudinal Analysis and Latent Growth Modeling of the Modified Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR)

The Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) was developed as a short-form survey to measure progress after total hip arthroplasty (THA). However, the longitudinal validity of the scale structure pertaining to the modified five-item HOOS-JR has not been assessed. Therefore, the purpose of this study was to evaluate the structural validity, longitudinal invariance properties, and latent growth curve (LGC) modeling of the modified five-item HOOS-JR in a large multi-site sample of patients who underwent a THA. A longitudinal study was conducted using data from the Surgical Outcome System (SOS) database. Confirmatory factor analyses (CFAs) were conducted to assess the structural validity and longitudinal invariance across five time points. Additionally, LGC modeling was performed to assess the heterogeneity of the recovery patterns for different subgroups of patients. The resulting CFAs met most of the goodness-of-fit indices (CFI = 0.964-0.982; IFI = 0.965-0.986; SRMR = 0.021-0.035). Longitudinal analysis did not meet full invariance, exceeding the scalar invariance model (CFIDIFF = 0.012; χ2DIFF test = 702.67). Partial invariance requirements were met upon release of the intercept constraint associated with item five (CFIDIFF test = 0.010; χ2DIFF = 1073.83). The equal means model did not pass the recommended goodness-of-fit indices (CFIDIFF = 0.133; χ2DIFF = 3962.49). Scores significantly changed over time, with the highest scores identified preoperatively and the lowest scores identified at 2- and 3-years postoperatively. Upon conclusion, partial scalar invariance was identified within our model. We identified that patients self-report most improvements in their scores within 6 months postoperatively. Females reported more hip disability at preoperative time points and had faster improvement as measured by the scores of the modified five-item HOOS-JR.