Why still in hospital after fast-track hip and knee arthroplasty?

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).     

What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway?

INTRODUCTION

Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway.

METHODS

An English language literature search was performed using the MEDLINE® and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review.

RESULTS

The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay.

CONCLUSIONS

There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.     

Long term outcomes of total knee arthroplasty in valgus knees – a fifteen year follow-up

Total knee arthroplasty (TKA) in valgus knees is a surgical challenge. This article describes our surgical technique and evaluates the long term outcomes of TKA in valgus knees. We found significant improvement in tibiofemoral angle, range of motion and HSS score post-operatively. Outcomes were comparable amongst osteoarthritis and rheumatoid arthritis patients. Complications were encountered in 16% of cases. Overall 15-year implant survival rate was 90.52%. Younger age, obesity and severe deformity were associated with higher risk of failure. Good clinical outcomes with satisfactory long term implant survival rates can be obtained in most cases of valgus TKA using standard medial parapatellar approach, unconstrained implants and judicious peri-articular soft tissue release.     

Comparison of survival and cost‐effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: A follow‐up study of 50,493 knee replacements from the Finnish Arthroplasty Register

Background and purpose Both unicondylar arthroplasty (UKA) and total knee arthroplasty (TKA) are commonly used for the treatment of unicompartmental osteoarthritis (OA) of the knee. The long‐term survivorship and cost‐effectiveness of these two treatments have seldom been compared on a nationwide level, however. We therefore compared the survival of UKA with that of TKA and conducted a cost‐benefit analysis comparing UKA with TKA in patients with primary OA.

Patients and methods We analyzed 1,886 primary UKAs (3 designs) and 48,607 primary TKAs that had been performed for primary OA and entered in the Finnish Arthroplasty Register between 1980 and 2003 inclusive.

Results UKAs had a 60% (95% CI: 54–66) survival rate and TKAs an 80% (95% CI: 79–81) survival rate at 15 years with any revision taken as the endpoint. Overall survival of UKAs was worse than that of TKAs (p < 0.001). All 3 UKA designs had poorer overall survival than the corresponding TKA designs. In the theoretical cost‐benefit analysis, the cost saved by lower implant prices and shorter hospital stay with UKA did not cover the costs of the extra revisions.

Interpretation At a nationwide level, UKA had significantly poorer long‐term survival than TKA. What is more, UKA did not even have a theoretical cost benefit over TKA in our study. Based on these results, we cannot recommend widespread use of UKA in treatment of unicompartmental OA of the knee.     

The clinical outcome of revision knee replacement after unicompartmental knee arthroplasty versus primary total knee arthroplasty: 8–17 years follow-up study of 49 patients

When unicompartmental knee arthroplasty (UKA) failure occurs, a revision procedure to total knee arthroplasty (TKA) is often necessary. We compared the long-term results of this procedure to primary TKA and evaluated whether they are clinically comparable. Twenty-one patients underwent UKA conversion to TKA between 1991 and 2000. The results of these patients were compared to the group of 28 primary TKA patients with the same age, sex and operation time point. The long-term outcomes were evaluated using clinical and radiological analysis. The mean follow-up period of the patients was 10.5 years. The UKA revision patients were more dissatisfied, as measured by the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scale (0–100 mm) compared to the primary TKA patients (pain 18.1/7.8; p = 0.014; stiffness 25.7/14.4, p = 0.024; physical function 19.0/14.8, p = 0.62). Two patients were revised twice in the UKA revision group. There was one revision in the primary TKA group (p = 0.39). Improvement in range of motion (ROM) was better in the TKA patients compared to the UKA revision patients (8.2°/–2.6°, p = 0.0001). We suggest that UKA conversion to TKA is associated with poorer clinical outcome as compared to primary TKA.     

Long term results of arthrodesis of the wrist: A 6–15 year follow up of 35 patients

A total of 40 wrists in 35 patients were investigated 10.5 (range 6–15) years after arthrodesis. The most common diagnosis was rheumatoid disease. There were 21 Mannerfelt, and 21 plate, arthrodeses. The patients were assessed clinically and up-to-date radiographs obtained. Two Mannerfelt arthrodeses had failed to fuse. Pain during the last week before review and total satisfaction with the operation were excellent in 28 and 30 wrists, respectively. The mean score on the “Disability of arm, shoulder and hand” (DASH) questionnaire was 38 (range 2–75). Plate arthrodeses gave better results than Mannerfelt arthrodeses for all variables studied. Wrists plated in dorsal extension gave the best scores for function and strength. We conclude that either method gives good long term results. Although few of the individual differences were statistically significant, we think that fusion with plates, and in particular plates with dorsal extension, is preferable.     

Long-term outcomes following total hip and total knee arthroplasty in patients with Paget's disease of bone (PDB) – A national study

BackgroundThe incidence of total hip and total knee arthroplasty (THA/TKA) is 3.1- and 1.7-fold higher in patients with Paget's disease of bone (PDB) compared to age-matched controls. No large studies or joint registry reports exist describing outcomes following THA or TKA in PDB patients.MethodsThe study objectives were to investigate the outcomes following THA or TKA in PDB patients using national registry data. Data were requested from the Scottish Arthroplasty Project for all PDB patients undergoing THA or TKA in Scotland from 1996 to 2013.ResultsBetween 1996 – 2013, 144 patients underwent primary THA and 43 patients underwent primary TKA for PDB in Scotland. Following primary THA, the most common surgical complications within one year were haematoma (1.4%), and surgical-site infection (1.4%). The overall incidence of dislocation was 2.8%. Revision THA was performed in 2.8% of patients. THA implant survival was 96.3% (CI:92.8–99.8) at 10-years, and patient survival was 50.0% (CI:39.6–60.4) at 10-years. Following TKA, only one revision surgery occurred within one year (2.3%). Revision TKA was performed in 4.7% of patients, across the whole study period. TKA implant survival was 94.5% (CI:87.1–100) at 10-years; patient survival was 38.3% (CI:16.7–59.9) at 10-years. Compared with published literature and registry data, implant longevity and patient survival are comparable between PDB patients and the general population.ConclusionThis is the largest reported series of outcomes following primary THA/TKA in PDB patients. PDB patients are not at increased risk of surgical complications following primary THA or TKA compared with the general population.     

Reduced length of stay following hip and knee arthroplasty in Denmark 2000–2009: from research to implementation

Introduction  

Fast-track surgery is the combination of optimized clinical and organizational factors aiming at reducing convalescence and perioperative morbidity including the functional recovery resulting in reduced hospitalization. As the previous nationwide studies have demonstrated substantial variations in length of stay (LOS) following standardized operations such as total hip and knee arthroplasty (THA and TKA), this nationwide study was undertaken to evaluate the implementation process of fast-track THA and TKA in Denmark.     

Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up

Introduction  In a prospective randomized study, we compared the results after implantation of the mobile bearing high flex TKA with a fixed bearing posterior stabilized TKA in 60 patients (30 patients each group). Method  We evaluated the hospital for special surgery-score (HSS) and different radiological parameters preoperatively, as well as 3 months, 3 and 5 years postoperatively. Result  Three months postoperatively, the high flex group showed better results in scores for pain, ROM (122.5° vs. 107.33°), as well as in the overall HSS (87.21 vs. 82.68 points). Three and 5 years postoperatively, there were no differences between both the groups in all scores, but the HSS is still increasing. Conclusion  The theoretical advantages of the mobile bearing knee prostheses were reflected in the clinical results, only partly and temporarily.     

Poor maintenance of sinus rhythm after electrical cardioversion of patients with atrial fibrillation or flutter: a 5‐year follow‐up of 268 consecutive patients

Objective—To report long‐term results of direct current (DC)‐cardioversion in unselected patients with atrial fibrillation (AF) or flutter.

Design—The study was a retrospective 5‐year follow‐up of all patients undergoing DC‐cardioversion for AF or flutter at our institution between 1993 and 1997.

Results—Three hundred and eighty‐five DC‐cardioversions were performed in 268 patients. Two hundred and forty‐nine patients underwent cardioversion for the first time. Of these, 183 (74%) were converted to sinus rhythm. During the first month of follow‐up 105 (57%) relapsed into AF. Only 33 patients (13%) of the 249 patients scheduled for cardioversion remained in sinus rhythm after 1 year. In multivariate analysis arrhythmia duration was the only variable that was associated with successful cardioversion. Periprocedural complications occurred in 9.9% of the cardioversions.

Conclusion—In daily routine only a minority of patients will maintain sinus rhythm after DC‐cardioversion for AF or flutter. Also, DC‐cardioversion is not without risk. These observational data suggest a conservative approach to re‐establishment of sinus rhythm in patients with AF.     

Worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty: A cross-sectional questionnaire study of 1,476 patients 1–3 years after surgery

Background

The surgical approach in total hip arthroplasty (THA) is often based on surgeon preference and local traditions. The anterior muscle-sparing approach has recently gained popularity in Europe. We tested the hypothesis that patient satisfaction, pain, function, and health-related quality of life (HRQoL) after THA is not related to the surgical approach.

Patients

1,476 patients identified through the Norwegian Arthroplasty Register were sent questionnaires 1–3 years after undergoing THA in the period from January 2008 to June 2010. Patient-reported outcome measures (PROMs) included the hip disability osteoarthritis outcome score (HOOS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), health-related quality of life (EQ-5D-3L), visual analog scales (VAS) addressing pain and satisfaction, and questions about complications. 1,273 patients completed the questionnaires and were included in the analysis.

Results

Adjusted HOOS scores for pain, other symptoms, activities of daily living (ADL), sport/recreation, and quality of life were significantly worse (p < 0.001 to p = 0.03) for the lateral approach than for the anterior approach and the posterolateral approach (mean differences: 3.2–5.0). These results were related to more patient-reported limping with the lateral approach than with the anterior and posterolateral approaches (25% vs. 12% and 13%, respectively; p < 0.001).

Interpretation

Patients operated with the lateral approach reported worse outcomes 1–3 years after THA surgery. Self-reported limping occurred twice as often in patients who underwent THA with a lateral approach than in those who underwent THA with an anterior or posterolateral approach. There were no significant differences in patient-reported outcomes after THA between those who underwent THA with a posterolateral approach and those who underwent THA with an anterior approach.The approach used for total hip arthroplasty (THA) is often based on the surgeon’s preference and local traditions. In 2011, 7,360 primary THAs were reported to the Norwegian Arthroplasty Register (NAR) (Norwegian Arthroplasty Register Annual Report 2012). A lateral approach was used in 53% of the operations, the posterolateral approach in 28%, and an anterior approach in 16%. Anterior muscle-sparing approaches have gained popularity because it has been argued that patients with such surgical approaches have less pain, shorter length of stay, and shorter rehabilitation time. These are short-term effects (Rodriguez et al. 2014), and the long-term effects are not well documented.The anterior approaches used in Norway are either a modified Smith-Petersen approach (Smith-Petersen 1949, Judet and Judet 1950) or an anterolateral Watson-Jones approach (Watson-Jones 1936). These may have a longer learning curve (Greidanus et al. 2013) and a higher incidence of early revision (Spaans et al. 2012, Lindgren et al. 2012). The lateral approach (Hardinge 1982) divides the anterior portion of gluteus medius and minimus. Muscular-tendon suture or osteosuture is used to reinsert the tendon into the trochanteric area. This approach has been blamed for increasing the risk of damage to the superior gluteal nerve and to the gluteus medius muscle (Jolles and Bogoch 2006, Arthursson et al. 2007, Khan and Knowles 2007).The posterolateral approach involves division of the piriformis, obturator internus, and gemelli tendons (Pellicci et al. 1998). This approach is considered to have less effect on gait since the abductor muscles are not dissected (Shaw 1991, Hedlundh et al. 1995), but it has been associated with an increased risk of dislocations, with risk of injury to the sciatic nerve. More recent studies have shown that use of larger femoral head sizes can markedly reduce the dislocation rate (Amlie et al. 2010, Bistolfi et al. 2011, Ho et al. 2012).We compared the different approaches with regard to patient satisfaction, pain, function, and HRQoL after primary THA.     

Enhanced recovery program – Impact of ASA grade on length of hospital stay in patients undergoing hip and knee arthroplasties

IntroductionTotal hip and knee arthroplasties are two of the most quality of life enhancing orthopedic procedures performed. Enhanced recovery (ER) programs have been implemented in orthopedic surgery and have helped optimize preoperative, perioperative, and postoperative factors to reduce the physiological and psychological stress of surgery. The American Society of Anesthesiologists [ASA] classification system is now the most widely collected system for measuring physical health status by hip and knee arthroplasty registries worldwide. The aim of the study is to determine whether the ASA score is a predictive of length of hospital stay in patients undergoing hip and knee surgeries in elective setting.MethodsRetrospective data is collected from a consecutive series of 441 charts and Irish National Orthopedics Register (INOR) for patients who underwent elective primary hip & knee replacements from January 1, 2018 to December 31, 2018 in Our Lady's Hospital, Navan. All these patients were assigned either ASA Class 2 or 3 in preoperative assessment.ResultsTotal 441 patients were included. Patients with ASA 2 (319 patients of the total patient for the same period), average length of hospital stay was 4.8 ± 1.2 days, whereas for patients with ASA 3 (122 patients of the total), length of hospital stay was 6.5 ± 2.3 with mean difference between two groups was 1.7 days (95% confidence interval of this difference).ConclusionPatients with ASA 2 stayed shorter in the hospital compared to patients with ASA 3. Therefore, we recommend that pre-operative patients' optimization to downgrade a patient from an ASA 3 to ASA 2, but prospective analysis would be beneficial to examine the resource implications of such an initiative as well as patient outcomes with longer term follow up.     

Dissatisfied patients after total knee arthroplasty: A registry study involving 114 patients with 8–13 years of follow-up

Background and purpose

In 2003, an enquiry by the Swedish Knee Arthroplasty Register (SKAR) 2–7 years after total knee arthroplasty (TKA) revealed patients who were dissatisfied with the outcome of their surgery but who had not been revised. 6 years later, we examined the dissatisfied patients in one Swedish county and a matched group of very satisfied patients.

Patients and methods

118 TKAs in 114 patients, all of whom had had their surgery between 1996 and 2001, were examined in 2009–2010. 55 patients (with 58 TKAs) had stated in 2003 that they were dissatisfied with their knees and 59 (with 60 TKAs) had stated that they were very satisfied with their knees. The patients were examined clinically and radiographically, and performed functional tests consisting of the 6-minute walk and chair-stand test. All the patients filled out a visual analog scale (VAS, 0–100 mm) regarding knee pain and also the Hospital and Anxiety and Depression scale (HAD).

Results

Mean VAS score for knee pain differed by 30 mm in favor of the very satisfied group (p < 0.001). 23 of the 55 patients in the dissatisfied group and 6 of 59 patients in the very satisfied group suffered from anxiety and/or depression (p = 0.001). Mean range of motion was 11 degrees better in the very satisfied group (p < 0.001). The groups were similar with regard to clinical examination, physical performance testing, and radiography.

Interpretation

The patients who reported poor response after TKA continued to be unhappy after 8–13 years, as demonstrated by VAS pain and HAD, despite the absence of a discernible objective reason for revision.The results of TKA are regarded as being favorable (Robertsson et al. 2000, Kane et al. 2005, Nilsdotter et al. 2009, Carr et al. 2012) with few surgical complications and a revision rate of less than 5% after 10 years (Vessely et al. 2006, Robertsson et al. 2010). Poor outcome after primary TKA, apart from the revision, is between 6% and 14% (Anderson et al. 1996, Hawker et al. 1998, Heck et al. 1998, Robertsson et al. 2000, Robertsson and Dunbar 2001, Brander et al. 2003, Noble et al. 2006, Fisher et al. 2007, Wylde et al. 2008, Kim et al. 2009, Bourne et al. 2010, Scott et al. 2010). The reason for poor outcome after TKA may be related to problems with the knee surgery itself, although it has been suggested that extra-articular causes such as hip disease, spine disorder, vascular disease, or reflex sympathetic dystrophy may contribute. Some studies have suggested that factors not primarily related to structural tissue changes, but of psychological nature instead, may be involved (Wylde et al. 2007, Rolfson et al. 2009).The Swedish Knee Arthroplasty Register (SKAR) registers primary arthroplasties performed in Sweden as well as revisions, and has been estimated to capture 97% of the surgeries performed (SKAR 2012). The SKAR sends questionnaires regarding satisfaction to patients who were operated on during certain time periods (Robertsson et al. 2000, and Dunbar 2001). We used the SKAR to identify patients who had not undergone revision surgery and who were dissatisfied with their outcome 2–7 years after TKA surgery. As a reference we chose an age-, sex-, date-of-surgery-, and hospital-matched control group of highly satisfied patients who were operated during the same period. Our aim was to assess the differences between these 2 patient groups.     

Trends in the incidence of acute myocardial infarction and stroke: a 21‐year follow‐up of the Oslo study

Objective --In spite of the advances in technology and surgical techniques, cardiac surgical operations with the use of cardiopulmonary bypass (CPB) are still associated with pulmonary morbidity and mortality. The purpose of this study is to morphologically analyze the structure of air-blood barriers in patients who underwent coronary artery bypass grafting (CABG) with use of CPB. Design --The investigation involved 50 patients aged 48-75 who underwent CABG with the use of extracorporeal circulation (ECC). Lung tissue specimens, which were taken before and after CPB, were observed with light and electron microscopy. Results --Both light and electron microscopic observations of pre-pump specimens did not show any pathological changes within the terminal part of the respiratory system. Morphological observations of tissue samples obtained after CPB revealed features of air-blood barrier injury and presence of surfactant within the alveolar capillaries. Conclusion --Whatever the mechanism of the aforementioned changes one should be aware that the presented results indicate that air-blood barriers become leaky after CABG is performed with the aid of ECC.     

Total knee arthroplasty after high tibial osteotomy: a registry-based case–control study of 1,036 knees

Introduction

Total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is a technically demanding procedure, and concerns have been raised that previous HTO might compromise the outcome of TKA. The aims of the study were to assess the survivorship of TKA after HTO and to determine whether the survivorship is similar to that of primary TKA without previous HTO.

Materials and methods

Using the Finnish Arthroplasty Register and the National Hospital Discharge Register, we extracted the data of 1,036 patients [mean age 64.3 years; followup 6.7 years (0–22)] who had undergone TKA after a previous HTO between 1987 and 2008. From this cohort, we calculated the Kaplan–Meier survivorship and compared the survivorship of these cases to that of 4,143 age- and gender-matched patients who had undergone primary TKAs without previous HTO.

Results

In the TKA after HTO group, we found Kaplan–Meier survivorship to be 95.3 % at 5 years, 91.8 % at 10 years, and 88.4 % at 15 years. Those survivorship values were lower than those of patients who had TKA without previous HTO (97.2, 94.5, and 90.6 %, respectively) (hazard ratio 1.40; 95 % confidence interval 1.09–1.81; p = 0.010).

Conclusions

Previous studies have described technical difficulties during the TKA procedure after HTO, but they have found no adverse effects on the outcome. Our study supports previous research, and despite the slightly higher revision rate, TKA after HTO provides satisfactory results when compared to routine primary TKAs.