Opioid use, postoperative complications, and implant survival after unicompartmental versus total knee replacement: a population-based network study.

Edward Burn,Dahai Yu,Ruth Costello,Albert Prats-Uribe,David Culliford,Spyros Kolovos,Luis H John,Antonella Delmestri,James Weaver,Nigel Hughes,Michel Van Speybroeck,Belay Birlie,Ying He,Rafael Pinedo-Villanueva,Theresa Burkard,Victoria Y Strauss,William Sproviero,Daniel Moralès ,Anthony G Sena ,H V Morgan ,Caroline O’leary ,Talita Duarte‐Salles ,Ross D Williams ,Danielle Robinson ,Daniel Prieto‐Alhambra ,Patrick B Ryan

doi:10.1016/s2665-9913(19)30075-x

Abstract

There is uncertainty around whether to use unicompartmental knee replacement (UKR) or total knee replacement (TKR) for individuals with osteoarthritis confined to a single compartment of the knee. We aimed to emulate the design of the Total or Partial Knee Arthroplasty Trial (TOPKAT) using routinely collected data to assess whether the efficacy results reported in the trial translate into effectiveness in routine practice, and to assess comparative safety. We did a population-based network study using data from four US and one UK health-care database, part of the Observational Health Data Sciences and Informatics network. The inclusion criteria were the same as those for TOPKAT; briefly, we identified patients aged at least 40 years with osteoarthritis who had undergone UKR or TKR and who had available data for at least one year prior to surgery. Patients were excluded if they had evidence of previous knee arthroplasty, knee fracture, knee surgery (except diagnostic), rheumatoid arthritis, infammatory arthropathies, or septic arthritis. Opioid use from 91-365 days after surgery, as a proxy for persistent pain, was assessed for all participants in all databases. Postoperative complications (ie, venous thromboembolism, infection, readmission, and mortality) were assessed over the 60 days after surgery and implant survival (as measured by revision procedures) was assessed over the 5 years after surgery. Outcomes were assessed in all databases, except for readmission, which was assessed in three of the databases, and mortality, which was assessed in two of the databases. Propensity score matched Cox proportional hazards models were fitted for each outcome. Calibrated hazard ratios (cHRs) were generated for each database to account for observed differences in control outcomes, and cHRs were then combined using meta-analysis. 33 867 individuals who received UKR and 557 831 individuals who received TKR between Jan 1, 2005, and April 30, 2018, were eligible for matching. 32 379 with UKR and 250 377 with TKR were propensity score matched and informed the analyses. UKR was associated with a reduced risk of postoperative opioid use (cHR from meta-analysis 0·81, 95% CI 0·73-0·90) and a reduced risk of venous thromboembolism (0·62, 0·36-0·95), whereas no difference was seen for infection (0·85, 0·51-1·37) and readmission (0·79, 0·47-1·25). Evidence was insufficient to conclude whether there was a reduction in risk of mortality. UKR was also associated with an increased risk of revision (1·64, 1·40-1·94). UKR was associated with a reduced risk of postoperative opioid use compared with TKR, which might indicate a reduced risk of persistent pain after surgery. UKR was associated with a lower risk of venous thromboembolism but an increased risk of revision compared with TKR. These findings can help to inform shared decision making for individuals eligible for knee replacement surgery. EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative (2) Joint Undertaking (EHDEN).

Highlights

Knee replacement is one of the most common surgical procedures and typically leads to substantial improvements in pain, function and quality of life.1 there is variation in how knee replacements are performed
Prior research has found unicompartmental and total knee replacement (UKR and TKR) to result in broadly similar patient-reported outcomes, UKR to have a lower risk of some post-operative complications, notably venous thromboembolism, infection, and mortality, but TKR to have a lower risk of revision procedures
Arthroplasty Trial (TOPKAT), compared UKR and TKR, with 264 patients randomised into each arm of the trial

Summary

Introduction

Knee replacement is one of the most common surgical procedures and typically leads to substantial improvements in pain, function and quality of life. there is variation in how knee replacements are performed. Previous research has generally found UKR and TKR to result in broadly similar gains in patient-reported outcomes after surgery.. Previous research has generally found UKR and TKR to result in broadly similar gains in patient-reported outcomes after surgery.2 Both UKR and TKR are major orthopaedic procedures and so are accompanied by a risk of post-operative complications. Prior research has found unicompartmental and total knee replacement (UKR and TKR) to result in broadly similar patient-reported outcomes, UKR to have a lower risk of some post-operative complications, notably venous thromboembolism, infection, and mortality, but TKR to have a lower risk of revision procedures. Consistent with previous observational studies, post-operative patient-reported outcomes were similar at 5 years and fewer complications seen for those who had UKR.

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