Improving GIRFT compliance and patient experience of accessibility and shared decision making for elective hip and knee replacement: incorporation of a digital patient information leaflet.

IntroductionHyponatraemia has a prevalence of up to 30% after orthopaedic surgery and is associated with poor outcomes, including around 20% mortality and longer hospital stays. This study assessed the prevalence of hyponatraemia following total hip and knee replacement, the causes, further tests, management, effect on length of stay, intensive care admissions and the impact of an endocrinology hyponatraemia protocol.Materials and methodsDay one postoperative urea and electrolyte results for patients undergoing elective total hip and knee replacements were reviewed. Retrospective data was gathered through the web-based requesting and reporting system ICE. Parameters included demographics, procedure, sodium pre- and postoperatively, endocrine input, high-dependency admissions and length of hospital stay. Next, a hyponatraemia protocol based on NICE guidance was developed with the endocrinology department and a second audit cycle was initiated. SPSS software was used to analyse the data.ResultsHyponatraemia occurred in 12% of patients, resulted in a significantly longer stay (7.7 days vs 4.6, t –4.6, p < 0.00001) and multiple critical care admissions (8 days). It was more common in total knee replacement (chi square 5.5194, p = 0.018807) and older age (t –2.81083, p = 0.002619). Prior to implementation of the endocrine pathway, hyponatraemia was under-investigated (38%). The precipitating factors such as age and use of diuretics corroborated with prior research. Implementation of the hyponatraemia protocol resulted in quicker endocrinology referrals (2.3 vs 3.6 days), reduced length of stay by 0.7 days (t –2.40973, p = 0.008144) and reduced intensive care days to 0 (chi square 4.6189, p = 0.031622).DiscussionThis study found a similar incidence of hyponatremia as earlier research with the same precipitating factors, the only exception being an increased incidence in patients undergoing knee compared with hip replacemenr The introduction of the direct endocrine pathway proved to be safe and effective without increasing local workload significantly. The main limitation in this project was the fact that it was carried out in a single unit, although this process could be easily replicated should other units wish to adopt it and compare results over a wider cohort.ConclusionsThis endocrine pathway is easily reproducible for other departments. It may help reduce waiting times and improve outcomes for total hip and knee replacements within the NHS.

The Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear. To examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries. Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs). Starting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients' hospitalization for hip or knee replacement and 90 days after the hospital discharge. Beneficiary-level elective hip or knee replacement receipt in a given year. Among 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, -1.25 to -0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, -0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (-0.68, 95% CI, -1.20 to -0.15). In this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups.

Møller AM, Villebro N, Pedersen T, et al. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet2002 Jan 12; 359 : 114 –7 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4]...

This article is a report on a pilot study conducted to determine the effects of cognitively stimulating activities in older patients undergoing elective hip and/or knee replacement. Cognitive decline occurs in 16-35·5% of older hospitalized patients. In-hospital interventions, such as cognitively stimulating activities, might combat cognitive decline. However, evidence supporting such interventions is limited. For this randomized pilot trial, 50 older patients (90% women with a mean age of 72·8 years) were recruited in 2008 from a tertiary medical centre in Taiwan. While hospitalized, participants in the intervention group received a daily nurse-led, individual-based, cognitive-stimulation intervention. The comparison group received usual care. Cognitive function was assessed using Mini-Mental State Examination at admission, discharge and 1 month after discharge. The incidence of cognitive decline (≥2-point decline in cognitive score) by hospital discharge was significantly lower for the intervention group (12%) than the usual care group (44%). The intervention group also had better cognitive scores following hospitalization. Upon discharge, participants in the intervention group scored 1·28 points higher than at admission, whereas participants in the usual care declined by 0·76 points. Improvement in cognitive status persisted for the intervention group (+1·33 points) vs. usual care (-0·26 points) at 1 month after discharge. Group differences in changes were statistically significant both at discharge and 1 month afterwards. Our cognitive-stimulation intervention benefited global cognitive function among older patients undergoing elective hip and/or knee replacement. The benefit persisted at 1 month after discharge.

The objective of the analysis presented is to assess the efficacy of a fast-track pathway for elective hip and knee arthroplasty, compared to the traditional approach, adopted within a research hospital located in Milan (Italy), in terms of length of stay reduction and related direct medical costs. A monocentric observational retrospective study was implemented considering adult subjects who underwent elective primary total hip or knee replacement, with a diagnosis of primary or secondary osteoarthritis. Exclusion criteria were subjects admitted via emergency department, subjects undergoing knee or hip replacement because of fractures or prosthesis revision. The analysis compared the length of stay and the direct medical costs, assuming the hospital perspective, of subjects admitted in the pre-fast-track period (years 2016/2017) and during the fast-track period (years 2018/2019). Knee replacement mean costs are 5,599 € (±1,158.3 €) in the pre-fast-track period and 4,487 € (±978.4 €) in the fast-track period (-1,112 €; -19.9%). Hip replacement mean costs in the pre-fast-track period are 5,364 € (±1,037.2 €) and 4,450 € (±843.7 €) in the fast-track period (-914 €; -17.0%). The adoption of fast-track pathway led to a statistically significant decrease of days of hospitalization of -2.8 (-37.6%) in knee replacement and of -2.9 (-39.2%) in hip replacement. The fast-track pathway adopted proved to be effective, reducing patients' length of stay, and sustainable and efficient, reducing direct medical costs, for both elective hip and knee replacement surgeries.

Background and objectivePost-operative periprosthetic femoral fractures (POPFF) present a growing challenge for healthcare services, but there are limited national data on patient profiles, short-term outcomes, and post-discharge follow-up. We aimed to fill these gaps. MethodsUsing Hospital Episode Statistics (HES), we identified POPFF discharges from hospitals in England for patients aged 18 and above between April 2016 and December 2022. We flagged prior admissions for hip fracture and elective hip or knee replacement surgery (primary, revision or re-revision) between April 2000 and the day of the POPFF admission date. We extracted information on patient factors, treatment modes for POPFF (nonoperative, fixation, revision), and outcomes (in-hospital mortality, length of stay, unplanned readmission). We used outpatient data to summarise post-hospitalisation follow-up. ResultsOf 39,035 cases, 65.9 % were female; the median age was 82 years. HES data identified that 34.0 % had previously undergone elective hip replacement, 26.2 % elective knee replacement, and 22.8 % surgery for hip fracture. Those with a prior hip fracture were more likely to have delirium during the index POPFF admission, and, compared with those with a prior elective hip or knee replacement, they faced higher in-hospital mortality (5.1 % vs 3.2 % and 3.6 %, respectively), rates of readmission (15.4 % vs 13.1 % and 12.8 %, respectively), and hip re-fracture after POPFF (2.9 % vs 1.2 % and 1.6 %, respectively). Their median length of stay was longer (16 vs 14 days, p < 0.001). The most common reason for hospital readmission following POPFF was another fracture (11.3 % of all readmissions). Overall, 74 % of patients were discharged from outpatient follow-up within 12 months. ConclusionThis is the first national description of the burden of adverse outcomes for people with POPFF in England, of whom a large proportion require ongoing specialist support. Fewer POPFF cases follow prior hip fracture surgery than elective joint replacement, but these patients face higher risks of worse outcomes. With an expected increasing incidence of POPFF, this may have considerable health service implications.

Please confirm that an ethics committee approval has been applied for or granted: Not relevantBackground and AimsLEAP (Leicester Enhanced Arthroplasty Pathway) was initiated in accordance with the GIRFT (Getting It...

Purpose: Individual drugs for pain management may have different risk profile, especially among elderly individuals. We investigated the risk of mortality with use of analgesics during the first six months after discharge from elective hip or knee replacement surgery. Methods: Through cross-linkage of Danish nationwide administrative registers, we identified patients discharged alive after elective hip or knee replacement between mid 2004 and end 2009. Risk of mortality during the first six months associated with use of diclofenac, ibuprofen, naproxen, tramadol, and morphine was analyzed by multivariable time-dependent Cox proportional hazard regression. Results: In total 28,467 patients were included (60% women and mean age 69.0 (inter quartile range 61.6-76.5) years) of which 15,573 (55%) had a total hip replacement. A total of 2,459 patients received diclofenac, 7,044 ibuprofen, 379 naproxen, 9,851 tramadol, 11,696 paracetamol, and 6,679 morphine. During follow-up 380 patients died (21 in diclofenac, 37 in ibuprofen, 2 in naproxen, 80 in tramadol, 206 in paracetamol, and 87 in morphine treatment). The adjusted Cox regression analysis demonstrated that morphine and diclofenac were associated with increased mortality (Figure) while ibuprofen, naproxen, tramadol and paracetamol were not associated with increased risk. ![Figure][1] Figure 1 Conclusions: Treatment with diclofenac or morphine during the first six months after discharge from elective hip or knee replacement was associated with increased mortality-risk. Awareness on potential risk of adverse events associated with these drugs after hip- or knee-replacement surgery is warranted. [1]: pending:yes

Elective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery. We included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016-2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic. We included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic. The restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements.

An intra-operative splash is a common occurrence in elective knee and hip replacement surgery and can potentially transmit bloodborne diseases, with devastating consequences. This study aimed to quantify the risk of a splash and to assess its correlation with body mass index, duration of surgery and the volume of lavage fluid used. Between December 2007 and April 2008, 62 consecutive patients (38 women, 24 men) undergoing an elective total knee or total hip replacement (TKR, THR) were recruited into the study (32 TKRs and 30 THRs) after appropriate consent. A splash occurred in all 62 cases. A THR had a slightly higher risk of a splash than a TKR, but this was not statistically significant (p = 0.27). The correlation between body mass index, duration of surgery and the amount of pulse lavage used with a splash was r = 0.013, (non-significant), r = 0.52, (significant) and r = 0.92 (highly significant), respectively. A high number of splashes are generated during a TKR and a THR. The simple visor mask fails to protect the surgeon, the assistant or the patient from the risk of a splash and reverse splash, respectively.

Recent Advances in Venous Thromboembolic Prophylaxis in Major Orthopedic Surgery: A Regional Perspective

Evaluation of the Measurement Properties of Four Performance Outcome Measures in Patients with Elective Hip Replacements, Elective Knee Replacements, or Hip Fractures

AimsElective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery.MethodsWe included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016–2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic.ResultsWe included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic.ConclusionsThe restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements.

Urinary retention postoperatively is alarming complication that happened after elective hip and knee replacement surgeries. This literature review examined the incidence, risk factors, and management of postoperative urinary retention (POUR) in elective total hip and knee replacement surgery over the last five years.

Purpose of reviewParticipation in alternative payment models has focused efforts to improve outcomes and patient satisfaction while also lowering cost for elective hip and knee replacement. The purpose of this review is to determine if preoperative education classes for elective hip and knee replacement achieve these goals.Recent findingsRecent literature demonstrates that patients who attend education classes prior to surgery have decreased anxiety, better post-operative pain control, more realistic expectations of surgery, and a better understanding of their surgery. As a result, comprehensive clinical pathways incorporating a preoperative education program for elective hip and knee replacement lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost.SummaryIn summary, we report convincing evidence that preoperative education classes are an essential element to successful participation in alternative payment models such as the Bundle Payment Care Initiative.