Abstract
BackgroundLack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence.MethodsPart 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients.ResultsContinuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely.ConclusionRecommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.
Highlights
Total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeries are considered to be highly cost-effective treatments for end-stage osteoarthritis [1]
This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence
Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA
Summary
Total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeries are considered to be highly cost-effective treatments for end-stage osteoarthritis [1]. TKA and THA surgeries lend themselves to standardized care pathways during the acutecare period [10], as there are particular interventions which need to be routinely considered These interventions include the use of intravenous antibiotics peri-operatively for the prevention of joint infection and the use of chemoprophylaxis for the prevention of venous thromboembolism (VTE). There are other care processes in the pathway that address other aspects of recovery which are arguably not as critical These typically have not been addressed by guidelines despite the existence of high-level evidence regarding their use. These, in turn, can lead to unnecessary variation in costs associated with care and may contribute to unnecessary differences in outcomes between patients For these reasons, it is important to identify which interventions should or should not be routinely provided based on the best available evidence, and whether surgeon practices align with the evidence. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence
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