Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol

Routine Prescription of Proton Pump Inhibitors in the Perioperative Period is Associated with Decreased Rates of 2-Year Revision Surgery after Total Hip and Knee Arthroplasty

INTRODUCTION

Proton Pump Inhibitors (PPIs) are often prescribed in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) after total hip (THA) and total knee arthroplasty (TKA) due to their gastroprotective effects. In animal studies, it has been suggested that PPIs have immunosuppressive effects and impair fracture healing, however, the association between PPI use and adverse events following THA and TKA has not been well studied.

METHODS

An administrative claims database was queried for patients who underwent elective THA from 2010 to 2019. The experimental group consisted of patients who did not have a prior history of gastrointestinal (GI) bleeding or gastroesophageal reflux disease (GERD) and who received a PPI prescription in the perioperative period. A 1:1 propensity score matching was used to create control cohorts of patients who did not have any PPI prescription filled, also matching for age, sex, and Charlson comorbidity index. This same cohort selection and matching procedure was then repeated for patients undergoing elective TKA. In total, 11,450 patients were studied (3,103 TKA+PPI, 2,622 THA+PPI, 3,103 TKA Controls, and 2,622 THA Controls). The mean age was 64 years (range, 38 to 94), and 57% were women. Significance was considered at P < 0.05.

RESULTS

Perioperative PPI prescription in TKA patients was associated with significantly lower rates of all-cause revision (3.0 versus 4.1%, P < 0.01) and periprosthetic joint infection (1.0 versus 1.8%, P < 0.01). In THA patients, PPI prescription was associated with a lower all-cause revision rate (2.8 versus 4.0%, P = 0.02). No significant differences were found between PPI and non-PPI groups for aseptic loosening, periprosthetic fracture, gastrointestinal bleeding, or surgical site infection in either cohort.

CONCLUSIONS

Patients receiving routine PPI prescriptions in the perioperative period surrounding TKA and THA have a lower risk of all-cause revision surgery, and perioperative PPI use is associated with a decreased risk of PJI in patients undergoing TKA. As these results conflict with the few previous studies performed on this topic, additional controlled studies are warranted to fully elucidate the relationship between PPI use and adverse events after THA and TKA.

Outpatient Total Hip Arthroplasty Volume up Nearly 8-Fold After Regulatory Changes With Expanding Demographics and Unchanging Outcomes: A 10-Year Analysis

BACKGROUND

With the removal of total hip arthroplasty (THA) from the inpatient-only (IPO) lists, the orthopedic landscape across the United States has changed rapidly. Thus, this study aimed to: 1) characterize the change in THA volume for outpatient and inpatient surgeries; 2) elucidate demographical differences before and after removal from the IPO list; and 3) analyze 30-day complications, readmissions, and reoperations.

METHODS

The National Surgical Quality Improvement Program database was queried for primary THAs between January 2010 and December 2021. The primary outcome was the annual volume of outpatient and inpatient THAs. Secondary outcomes involved 30-day complications, readmissions, and reoperations. The variables between cohorts were analyzed using goodness-of-fit Chi-square tests with summary statistics.

RESULTS

Of the 332,423 THAs between 2010 and 2021, 88% were inpatient THAs (n = 292,974) and 12% were outpatient THAs (n = 39,449). From 2019 to 2021, the volume of inpatient THA decreased by 55% (42,779 to 19,075), while outpatient THA increased by 751% (2,518 to 21,424). Patients who had a THA after 2019 were older (P < .001), more commonly women (P < .001), white (P < .001), and more likely American Society of Anesthesiologists Class III (P < .001). The outpatient cohort had fewer 30-day complications, readmissions, and reoperations. The length of stay for both cohorts decreased until 2019, before increasing in 2020 and 2021 for inpatient THAs, while home discharge and operative time increased for both.

CONCLUSIONS

The volume of outpatient THA increased almost eightfold after its removal from the IPO lists in 2020. Despite expanding eligibility with older patients and more comorbidities, 30-day complications, readmissions, and reoperations remain low. These findings support the safe transition to outpatient THA with appropriate patient selection and optimization.

Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients

OBJECTIVES

Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety.

METHODS

This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings.

RESULTS

VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01.

CONCLUSIONS

Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.

Advances in Hip Replacement Surgery

Total hip arthroplasty (THA) is one of the most successful types of surgical operation, with some considering it "the operation of the century" [...].

Evolution of Concepts: Can Personalized Hip Arthroplasty Improve Joint Stability?

Hip arthroplasty procedures are successful and reproducible. However, within the first two post-operative years, hip dislocations are the most common cause for revisions. This is despite the majority of the dislocations having the acetabular component within what is described as the 'safe zone'. The limitations of such boundaries do not take into account the variability of individual hip anatomy and functional pelvic orientation that exist. An alternative concept to address hip instability and improve overall outcomes is functional acetabular orientation. In this review article, we discuss the evolution of concepts, particularly the kinematic alignment technique for hip arthroplasty and the use of large-diameter heads to understand why total hip arthroplasty dislocations occur and how to prevent them.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

A low dislocation rate after revision total hip arthroplasty performed through the anterior approach

BACKGROUND

Dislocation is a major complication in revision total hip arthroplasties. This study aimed to evaluate the dislocation rate, complications, and functional scores of revision total hip arthroplasty performed through the direct anterior approach.

METHODS

Between January 2014 and March 2020, 84 patients undergoing revision total hip arthroplasty were retrospectively reviewed. All operations were performed through the direct anterior approach. At the final follow-up, incidences of dislocation, reoperation, acute deep infections, periprosthetic fractures and psoas impingement were assessed. The median postoperative Oxford Hip Score was also calculated.

RESULTS

At revision surgery, the mean age was 66 ± 12 years (range, 28-91). During an average follow-up of 4.2 ± 1.2 years, reoperation rate for major complications in the non-infected revisions was 15% (n = 11), including five acute deep infections (7%), four periprosthetic fractures (5%), one dislocation and one psoas impingement (1%). The median postoperative Oxford Hip Score was 39 (interquartile range = 14).

CONCLUSION

In our series, revision total hip arthroplasty through direct anterior approach was associated with a very low dislocation rate, acceptable complication rates and good functional results. Our results suggest that this procedure is safe and reliable.

TRIAL REGISTRATION

Ethical approval for this study was obtained, before enrollment of the first participant, by CUB Erasme's research ethics committee (P2020/323) and C.H.U Ambroise Paré's research ethics committee.