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1.

Background and purpose

Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA.

Patients and methods

To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered.

Results

Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients.

Interpretation

Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.Total hip and total knee arthroplasty (THA and TKA) are frequent operations with an average length of stay (LOS) of about 6–12 days in the United Kingdom, Germany, and Denmark (Husted et al. 2006, Bundesauswertung 2009, NHS 2010).During the last decade, however, there has been increased interest in optimal multimodal perioperative care to enhance recovery (the fast-track methodology). Improvement of analgesia; reduction of surgical stress responses and organ dysfunctions including nausea, vomiting, and ileus; early mobilization; and oral nutrition have been of particular interest (Kehlet 2008, Kehlet and Wilmore 2008). These principles have also been applied to THA and TKA, resulting in improvements in pain treatment with multimodal opioid-sparing regimens including a local anesthetic infiltration technique (LIA) or peripheral nerve blocks to facilitate early mobilization (Ilfeld et al. 2006a, b, 2010a, Andersen et al. 2008, Kerr and Kohan 2008), and allowing functional rehabilitation to be initiated a few hours postoperatively (Holm et al. 2010)—ultimately leading to a reduction in LOS (Husted et al. 2008, Barbieri et al. 2009, Husted et al. 2010a, b). Using these evidence-based regimens combined with an improved logistical setup, LOS is reduced to about 2–4 days (Kerr and Kohan 2008, Husted et al. 2010 a,b,c, Lunn et al. 2011).Having well-defined functional discharge criteria is imperative in order to ensure a safe discharge—and it is mandatory if meaningful comparison of LOS is done following alterations in the track (Husted et al. 2008). In the same fast-track setting, an earlier study focused on patient characteristics predicting LOS (Husted et al. 2008). However, little is known about the specific reasons for why patients are hospitalized during the first 1–3 days after THA or TKA; i.e. why can patients not be discharged?We therefore analyzed clinical and organizational factors responsible for being hospitalized in a well-defined prospective setup in a fast-track unit. This unit had previously documented LOS of about 2–3 days (Andersen et al. 2008, Holm et al. 2010, Husted et al. 2010b, c, Lunn et al. 2011).  相似文献   

2.

Introduction

Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures.

Methods

A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures.

Results

Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n?=?290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n?=?298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p?<?0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p?=?0.95) and for major complication was not significantly different (OR 2.94, p?=?0.27). The overall mean savings including both THA and TKA was USD 298 per case.

Conclusions

In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures.Level of Evidence: Level I
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3.
BackgroundOutpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA.MethodsA 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123).ResultsTwenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables).ConclusionOne in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.  相似文献   

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Background

Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation.

Methods

The potential role of QUIXIL?, a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee.

Results

Results showed that application of 2?ml QUIXIL? adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P?=?0.026) was detected in QUIXIL? treated patients.

Conclusion

Regarding cost effectiveness and benefit no indication for the use of 2?ml QUIXIL? fibrin sealant in standard knee arthroplasty could be proofed statistically.  相似文献   

8.
Jamil W  Allami M  Choudhury MZ  Mann C  Bagga T  Roberts A 《Injury》2008,39(3):362-367
INTRODUCTION: Routine metalwork removal, in asymptomatic patients, remains a controversial issue. Current literature emphasises the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice. AIM: To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal in asymptomatic patients. METHODS: An analysis, by two independent observers, was performed on the postal questionnaire replies of 36% (500 out of 1390), randomly selected UK orthopaedic consultants. RESULTS: Four hundred and seven (81%) replies were received. A total of 345 (69%) were found to be suitable for analysis. The most significant results of our study (I) 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients; (II) 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under; (III) 87% of the practicing surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more; (IV) only 7% of practicing trauma surgeons who replied to this questionnaire have departmental or unit policy. CONCLUSION: Our results demonstrate that most practicing trauma surgeons do comply with the evidence presented in the little literature available. However, we do believe that a general policy for metalwork removal is essential. Such a policy should include guidelines specific to age groups and level of surgeon who should be performing the removal procedure. Such a document would require further validated studies but would eventually serve to steer surgeons in achieving best practice.  相似文献   

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Introduction  

The goal of this study was (1) to identify logistical and clinical areas of importance for length of stay (LOS) by identifying departments with short and long LOS and to evaluate their set-up; and (2) to evaluate patient satisfaction in relation to LOS.  相似文献   

11.
Because cardiac complications may predict long-term survival after carotid endarterectomy (CEA), this study evaluates contemporary outcome, including cardiac complications, after CEA. Patients in Connecticut hospitals undergoing CEA between 1991 and 2002 were identified using the state discharge database (Chime, Inc.; ). Of the 12,618 CEAs performed, there were 53 (0.4%) deaths, 155 (1.2%) neurologic complications, and 300 (2.4%) cardiac complications. Despite an increase in patient age (p < .0001, Kruskal-Wallis test) over time, there were decreases in mortality (p = .0001, chi-square), postoperative stroke (p = .001), and cardiac complications (p = .0003). Vascular surgeons performed a minority of the procedures in the state (11%), but there were fewer cardiac complications after CEA performed by vascular surgeons than general surgeons (0.8% vs 3.0%; p < .0001). Multivariable logistic regression demonstrated that the risk of a cardiac complication was elevated in patients operated on by a nonvascular surgeon, patients with previous heart disease or stroke, and the elderly. In a state with very high performance of CEA by general and nonvascular surgeons, postoperative mortality and neurologic complications remain low. However, there were fewer cardiac complications when a vascular surgeon performed the procedure. These results suggest that increased referral to vascular surgeons could improve procedural safety.  相似文献   

12.
The orthopaedic evidence base is far from ideal. In order to truly ensure the effectiveness of orthopaedic interventions, researchers must design and carry out high-quality randomized controlled trials that strive to minimize bias. Such endeavors will ultimately form a high-quality RCT evidence base, which can subsequently be integrated by systematic reviews and meta-analyses in order to provide clinicians with the best evidence for decision-making.  相似文献   

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Clinical results from the past 30 years have proven total hip arthroplasty (THA) to be an effective technique for treating arthritic and degenerative conditions of the hip. Though there is little question concerning the effectiveness THA in general, significant debate exists concerning the best technique for performing the procedure. Sir John Chamley's concept of low-friction arthroplasty (LFA), considered to be the gold standard for THA, employs a cemented fixation technique for both the femoral and acetabular components. Over time, the merits of cemented fixation have been called into question as significant percentages of LFA implants failed and required revision surgery. Hybrid total hip arthroplasty is a variation of LFA that employs cemented fixation of the femoral component with cementless fixation of the acetabular component. Intermediate-term clinical results of hybrid THA have shown it to be a promising technique, with revision rates of both the femoral and acetabular components superior to Chanley LFA studies at similar lengths of follow-up. Though these results are encouraging, long-term data from the hybrid THA studies are required before a conclusion can be made as to whether the hybrid method is in fact superior to the LFA technique for performing THA.  相似文献   

16.
Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic consequences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various applications in different presenting scenarios with a guide to surgical tips and tricks for managing this challenging condition.  相似文献   

17.
Dislocation is one of the most common complications of total hip arthroplasty. The use of constrained liners is an option for the management of chronic hip instability, typically used after other methods have failed. The purposes of this study were to evaluate the overall clinical outcomes and failure rates of a tripolar constrained liner design, to assess the radiographic outcomes of its use, and to examine whether various factors such as abductor mechanism quality and history of previous revision surgeries were associated with an increased risk of failure. Forty-three hips in 39 patients who had a mean follow-up of 51 months (range, 24–110 months) were reviewed. Ninety-one percent of the hips (39 of 43 hips) did not need any revisions over the study period. A new liner was implanted in all four failed hips with concurrent revision of the acetabular cup in three cases. No further dislocations occurred in this group. The mean hip score for surviving hips was 82 points (range, 38–100 points) at final follow-up. Radiographic evaluation revealed stable, well-fixed acetabular components in all surviving hips without progressive radiolucencies. No association was found between abductor muscle quality and the incidence of failure, but patients who experienced a constrained liner failure were more likely to have undergone at least one previous hip revision operation. Tripolar constrained acetabular liners can provide successful outcomes in patients with hip instability, although it is important not to rely on the use of a constrained liner alone in an attempt to compensate for other correctable factors such as component positioning.  相似文献   

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European Journal of Orthopaedic Surgery & Traumatology - Some reports suggested that the status of the opposite-side hip affects clinical outcomes of unilateral total hip arthroplasty (THA) for...  相似文献   

20.

Background

Surgeon-dependent factors such as optimal implant alignment are thought to play a significant role in outcome following primary total knee arthroplasty (TKA). Exact definitions and references for optimal alignment are, however, still being debated. This overview of the literature describes different definitions of component alignment following primary TKA for (1) tibiofemoral alignment in the AP plane, (2) tibial and femoral component placement in the AP plane, (3) tibial and femoral component placement in the sagittal plane, and (4) rotational alignment of tibial and femoral components and their role in outcome and implant survival.

Methods

We performed a literature search for original and review articles on implant positioning following primary TKA. Definitions for coronal, sagittal, and rotational placement of femoral and tibial components were summarized and the influence of positioning on survival and functional outcome was considered.

Results

Many definitions exist when evaluating placement of femoral and tibial components. Implant alignment plays a role in both survival and functional outcome following primary TKA, as component malalignment can lead to increased failure rates, maltracking, and knee pain.

Interpretation

Based on currently available evidence, surgeons should aim for optimal alignment of tibial and femoral components when performing TKA.Total knee arthroplasty (TKA) is one of the most frequently performed orthopedic procedures, with an estimated 700,000 primary TKAs performed annually in the USA alone (National Hospital Discharge Survey 2010). While survival of primary TKAs is excellent, as most registries report 10-year survival of close to 95% for most implants (Graves et al. 2013, NJR 2013), recent studies have indicated that patient satisfaction is substantially worse. Up to 20% of the patients are not satisfied with the outcome as assessed 1 year postoperatively (Bourne et al. 2010, Klit et al. 2014) and a recent review found that 10–34% of patients had pain 3 months to 5 years after TKA (Beswick et al. 2012). Although patient-related factors (such as age, preoperative OKS and EQ5D, comorbidities, general health, depression, anxiety, and ASA) have been found to influence patient-reported outcome the most, surgical factors such as implant brand, hospital type (Baker et al. 2012), and implant alignment are also important (Choong et al. 2009, Longstaff et al. 2009).Implant malalignment following primary TKA has been reported to be the primary reason for revision in 7% of revised TKAs (Schroer et al. 2013) and it has been linked to both decreased implant survival (Ritter et al. 2011) and inferior patient-reported outcomes (Choong et al. 2009, Longstaff et al. 2009). However, optimal alignment still remains a matter of controversy, as several recent reports have found little or no correlation between postoperative tibiofemoral malalignment in the coronal plane and revision rates (Morgan et al. 2008, Parratte et al. 2010, Bonner et al. 2011). The emergence of computer navigation (Fu et al. 2012) and patient-specific cutting blocks (Lachiewicz and Henderson 2013)—with the proposed benefits of improved component positioning and fewer outliers—have further fueled this debate, as benefits in survival and patient related outcome are not apparent. Also, kinematic alignment (as opposed to mechanical alignment) in TKA has been debated in recent years as inherently, it does not adhere to traditional thinking concerning implant positioning and it is intended to improve postoperative outcome (Howell et al. 2013a).We investigated whether the literature supports definitions of optimal alignment following primary TKA surgery and whether a correlation between malalignment and inferior outcome could be identified. The following parameters were investigated separately: (1) tibiofemoral alignment in the AP plane; (2) tibial and femoral component placement in the AP plane; (3) tibial and femoral component placement in the sagittal plane; and (4) rotational alignment of tibial and femoral components.  相似文献   

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