Elective Primary Total Hip Research Articles

Associations Between Patients' Primary Language and Outcomes and Patient Engagement Process Metrics for Total Joint Arthroplasty.

Previous research has indicated language-based disparities in outcomes after total hip and knee arthroplasty. In this study, we examined the relationship between primary spoken language and outcomes and patient engagement process metrics in a multihospital academic health system. This retrospective cohort study included patients who underwent elective primary total hip or knee arthroplasty in 2018 to 2022. Primary language was categorized as English, Spanish, and Other. Associations were examined between language and perioperative outcomes (same-day discharge, extended hospital length of stay, nonhome discharge, 30-day hospital returns, 90-day readmissions, and 90-day combined complications), and engagement-related metrics (preoperative joint class attendance and patient-reported outcome measure [PROM] completion). We report adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Among 8,220 patients (7.9% Spanish and 5.1% Other non-English), we found no notable associations between language and same-day discharge, nonhome discharge, 30-day hospital returns, 90-day readmissions, or 90-day complications. Other (versus English) language was significantly associated with decreased odds of extended length of stay (OR 0.49, 95% CI, 0.32 to 0.76, P = 0.001). In patient engagement, Other (versus English) language was associated with significantly decreased odds of preoperative class attendance (OR 0.72, 95% CI, 0.54 to 0.95, P = 0.02). Spanish (versus English) primary language was significantly associated with decreased odds of preoperative and 1-year PROM completion (OR 0.34 to 0.75, P ≤ 0.001), and Other (versus English) primary language was significantly associated with decreased odds of preoperative PROM completion (OR 0.59, 95% CI, 0.47 to 0.73, P < 0.001). Our findings highlight language-based disparities in patient engagement metrics but comparable outcomes. Differences in findings compared with past literature may be related to institution-specific language-related support systems. There is a need for additional resources to support patients' active participation in their care, regardless of their primary spoken language.

Estimated Carbon Savings from Changing Surgical Trends in Primary Elective Total Hip Arthroplasty in England: A Retrospective Observational Study.

The National Health Service (NHS) in England has set a target to be net zero for carbon emissions by 2045. The aim of this study was to investigate how changes in key aspects of clinical practice over the last 8 years have contributed towards reducing the per-patient carbon footprint of elective total hip arthroplasty (THA). This was a retrospective analysis of administrative data. Data were extracted from the Hospital Episode Statistics database for all adult (≥ 17 years), primary, elective THA procedures conducted in England from 1 April, 2014 to 31 March, 2022. The estimated carbon footprint for key elements of the surgical pathway were calculated based on data from Greener NHS and the Sustainable Healthcare Coalition. Data were available for 537,441 THA procedures conducted during the study period. The per-patient carbon footprint associated with the primary THA (index) procedure fell by around 25% from 2014/15 to 2021/22. Length of stay was by far the largest contributor to this decline, falling from 169.1 kgCO2e to 117.6 kgCO2e per patient from 2014/15 to 2021/22. Absolute declines in the carbon footprint associated with emergency readmissions, revisions and outpatient attendances were more modest. If all patients in all years had the 2021/22 average carbon footprint, then carbon equivalent to powering 19,976 UK homes for 1year would have been saved. Improving per-patient efficiency of surgery is likely to contribute towards meeting the NHS's net-zero target whilst also helping to improve patient outcomes, reduce costs and cut waiting lists.

Health Technology Assessment for Fast-Track Elective Knee and Hip Arthroplasty in a High-Volume Orthopaedic Hospital in Italy.

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.

Impact of diabetic kidney disease on post-operative complications after primary elective total hip arthroplasty: a nationwide database analysis

BackgroundThe high prevalence of diabetic kidney disease (DKD) in the United States necessitates further investigation into its impact on complications associated with total hip arthroplasty (THA). This study utilizes a large nationwide database to explore risk factors in DKD cases undergoing THA.MethodsThis research utilized a case–control design, leveraging data from the national inpatient sample for the years 2016 to 2019. Employing propensity score matching (PSM), patients diagnosed with DKD were paired on a 1:1 basis with individuals free of DKD, ensuring equivalent age, sex, race, Elixhauser Comorbidity Index (ECI), and insurance coverage. Subsequently, comparisons were drawn between these PSM-matched cohorts, examining their characteristics and the incidence of post-THA complications. Multivariate logistic regression analysis was then employed to evaluate the risk of early complications after surgery.ResultsDKD's prevalence in the THA cohort was 2.38%. A 7-year age gap separated DKD and non-DKD patients (74 vs. 67 years, P < 0.0001). Additionally, individuals aged above 75 exhibited a substantial 22.58% increase in DKD risk (49.16% vs. 26.58%, P < 0.0001). Notably, linear regression analysis yielded a significant association between DKD and postoperative acute kidney injury (AKI), with DKD patients demonstrating 2.274-fold greater odds of AKI in contrast with non-DKD individuals (95% CI: 2.091–2.473).ConclusionsThis study demonstrates that DKD is a significant risk factor for AKI in patients undergoing total hip arthroplasty. Optimizing preoperative kidney function through appropriate interventions might decrease the risk of poor prognosis in this population. More prospective research is warranted to investigate the potential of targeted kidney function improvement strategies in reducing AKI rates after THA. The findings of this study hold promise for enhancing preoperative counseling by surgeons, enabling them to provide DKD patients undergoing THA with more precise information regarding the risks associated with their condition.

307 The Impact of Bone Quality on Surgical Decision-Making in Elective Primary Total Hip Arthroplasty: A Qualitative Analysis

307 The Impact of Bone Quality on Surgical Decision-Making in Elective Primary Total Hip Arthroplasty: A Qualitative Analysis

858 Post Operative Opioid Prescribing in Patients Undergoing Primary Elective Total Hip Replacement (THR): A Closed-Loop Clinical Audit

858 Post Operative Opioid Prescribing in Patients Undergoing Primary Elective Total Hip Replacement (THR): A Closed-Loop Clinical Audit

Pericapsular nerve group (PENG) block combined with local infiltration analgesia is not superior to local infiltration analgesia for the management of postoperative pain after primary elective total hip arthroplasty: A prospective, randomized, controlled, single-blind trial

BackgroundLocal infiltration analgesia (LIA) has been advocated for the pain management after total hip arthroplasty (THA). The analgesic benefits of an added pericapsular nerve group (PENG) block remain questionable. MethodsThis randomized, single-blind trial enrolled patients undergoing elective THA under general anaesthesia and standardized postoperative analgesia. Patients were allocated to receive either a PENG block (20 mL of ropivacaine 0.475 %) combined with intraoperative LIA (PENG + LIA group, n = 32), or intraoperative LIA alone (LIA group, n = 32). The primary outcome was oral morphine equivalent (OME) consumption at day 1. Secondary outcomes were: pain scores at post anaesthesia care unit (PACU) discharge and on day 2, times for the Timed to Up and Go (TUG) test and measurement of adductor strength on day 1, and patients’ satisfaction using the EVAN-G questionnaire. ResultsCompared with LIA alone, PENG + LIA resulted in similar OME consumption on day 1 (78 [51–91.5] mg vs 58 [30–80] mg respectively, median difference (95%CI) of −17 (−34 to 1) mg, p = 0.09). Pain scores and morphine consumption were not different between groups at any time point. TUG and thigh adduction tests were similar between LIA and PENG + LIA groups (respectively 35 [25–48.5] vs 31.5 [19.5–46.5] sec, p = 0.39; and 105 [85–150] vs 100 [80–125] mmHg, p = 0.61). No difference in the patients’ satisfaction was found. ConclusionThe addition of a PENG block to large-volume LIA did not significantly improve the analgesia for elective THA in the setting of an adequate basic postoperative analgesia regimen. The results of the lower limb functional tests confirmed the PENG block to be motor-sparing.

Do patients with osteoarthritis lose weight prior to elective joint replacement?

Obesity is a known risk factor for the development of osteoarthritis and the subsequent need for joint replacement. Weight loss has been shown to reduce pain, disability, and the need for joint replacement, particularly in patients with knee osteoarthritis. The aim of this study was to investigate pre-operative weight change in patients with hip, knee, and shoulder osteoarthritis at a regional, public hospital in Australia, to identify opportunities for pre-operative weight-loss intervention. A retrospective review of patients who underwent elective primary total hip (THR), knee (TKR), and shoulder (TSR) replacement for osteoarthritis was conducted between December 2019 and December 2022. BMI data were collected at three time points: (1) general practitioner (GP) referral; (2) orthopaedic clinic review; and (3) pre-admission clinic (PAC) assessment. A total of 496 patients were included in the study, of which 205 underwent THR, 251 underwent TKR, and 40 underwent TSR. The mean patient age was 67 years, and 46.4% were female. At the time of GP referral, the mean body mass index (BMI) was 31.4 kg/m2. Across the study period, only 2% of patients experienced clinically significant weight loss pre-operatively (≥5% of total body weight). This study has demonstrated that very few patients lose weight prior to undergoing joint replacement in the public sector in Australia. This highlights the need for targeted non-surgical weight loss interventions for patients currently awaiting joint replacement.

Complete Blood Count Ratios Predict Adverse Events After Total Joint Arthroplasty.

Complete blood count-based ratios (CBRs), including neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) are biomarkers associated with the proinflammatory surgical stress response. This study sought to determine whether preoperative CBRs are associated with postoperative complications, protracted hospital length of stay (LOS), and mortality after total joint arthroplasty, as well as establish threshold values for these outcomes for use in future investigations. The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary elective total hip arthroplasty or total knee arthroplasty (TKA). Approximate cut-point values for CBRs were identified by bootstrap simulation using the Youden index. Multivariable adjusted restricted cubic spline models using the predicted cut-point value as the threshold for odds of outcomes were created to identify a final threshold value associated with increased adjusted odds ratio (aOR) of study outcomes. A total of 32,868 total joint arthroplasties (THA: 12,807, TKA: 20,061) were identified. All measures predicted odds of aggregate postoperative complications (THA: NLR TV: 4.60 [aOR = 2.35], PLR TV: 163.4 [aOR = 1.32], MLR TV: 0.40 [aOR = 2.02], SII TV: 977.00 [aOR = 1.54]; TKA: NLR TV: 3.7 [aOR = 1.69], MLR TV: 0.41 [aOR = 1.62], PLR TV: 205.10 [aOR = 1.43], SII TV: 1,013.10 [aOR = 1.62]; all P < 0.05). A MLR > 0.40 [aOR = 1.54] P < 0.001) was associated with LOS ≥3 days after total hip arthroplasty while an NLR > 13.1 [aOR = 1.38] and an MLR > 0.41[aOR = 1.29] were associated with LOS ≥3 days after total knee arthroplasty (both P < 0.001). No association between inflammatory markers and inpatient mortality was observed. Given CBRs' ability to both predict outcomes and identify patients with a proinflammatory phenotype, the findings of this study provide a framework for future investigations aimed at identifying and treating high-risk patients with immune-modulating therapies. Continued work to validate these findings by applying TVs to interventional clinical trials is needed before wide clinical adoption.

Barriers and enablers to the implementation and sustainability of short-stay arthroplasty programs for elective primary total hip and knee replacement: A systematic review with qualitative evidence synthesis.

We aimed to systematically review contemporary evidence on the barriers and enablers to implementing and sustaining short-stay arthroplasty programs for elective primary total hip and knee replacement from the perspectives of patients, health professionals, carers, healthcare administrators, funders and policymakers and to map the findings to the Theoretical Domains Framework (TDF). Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (up to 19 August 2023). Primary qualitative or mixed-methods studies reporting on perspectives relating to the review aims that utilised a short-stay programme were eligible for inclusion. Study quality was assessed using the qualitative critical appraisal tool from the Joanna Briggs Institute. Data were analysed inductively. The final themes were mapped to the TDF. The confidence in the findings was assessed using GRADE CERQual. Fifteen studies were included. Twelve barrier themes and twelve enabler themes were identified. Three themes were graded with high confidence, 10 were graded with moderate confidence, three were graded with low confidence, and eight were graded with very low confidence. The most pertinent domains that the themes were mapped to for patients were beliefs about capabilities, reinforcement, and the environmental context and resources. Health professionals identified knowledge, environmental context and resources as important domains. Two domains were identified for carers: (1) social/professional role and identity and (2) memory, attention, and decision processes. We identified key barrier and enabler themes linked to the TDF that can be used to guide implementation initiatives and promote the sustainability of short-stay arthroplasty programs.

Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial

BackgroundHip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. MethodsConsenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. ResultsThere were no significant differences in 24-h opioid consumption (block vs sham block, mean difference −3.2 mg oral morphine equivalent, 95% confidence interval −15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. ConclusionsIn patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. Clinical trial registrationwww.clinicaltrials.gov (NCT03069183).

The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients

This systematic review and meta-analysis aimed to determine the impact of presurgical waiting times on pre-/post-operative joint specific pain and function, health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements. MEDLINE, EMBASE, PUBMED, and CENTRAL databases were searched from inception until 30th January 2023 (CRD42022288128). Secondary literature and unpublished datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded. PRISMA 2020 reporting and GRADE certainty of evidence guidelines were followed. Residual maximum likelihood meta-analysis and linear meta-regression was performed to elucidate the influence of presurgical waiting time. Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, capturing 89,996 patients (60.6% female, mean age 67.4 years) between 2001 and 2022. A significant deterioration in joint function (mean difference (MD):0.0575%; 95% CI 0.0064, 0.1086; p = 0.028(4d.p.); I2 = 73.1%) and HRQOL (MD: 0.05%; 95% CI − 0.0001.0009; p = 0.011(4 d.p.); I2 = 80.6%) was identified per additional day of waiting. Despite qualitative evidence, meta-analysis could not observe a relationship with postoperative outcome data. Patient responses to delayed THR and TKR surgery were unanimously negative. Immediate action should seek to reduce the increased patient anxiety and significant reductions in pre-operative joint functionality and HRQOL associated with prolonged pre-surgical waiting time, whilst mitigating any potential deleterious post-operative effects.

The Utility of the Area Deprivation Index in Assessing Complications After Total Joint Arthroplasty.

Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year. A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128). Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications. Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Efficacy of Nasal Screening and Methicillin-Resistant Staphylococcusaureus Decolonization in Total Hip Arthroplasty without Chlorhexidine Soap or Vancomycin.

Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a known risk factor for periprosthetic joint infection (PJI). In our facility, preoperative prophylaxis with mupirocin without the chlorhexidine soap scrub or vancomycin was consistently implemented for more than 15years. This study aimed to evaluate the current screening and treatment of intranasal MRSA colonization in our elective primary THA patient population. All patients who underwent primary THA between April 2011, and March 2021 were included in this analysis. All patients were screened preoperatively for nasal MRSA approximately 1month before surgery. Patients with nasal MRSA contamination are treated with topical mupirocin to eradicate the bacteria before surgery. The patients were examined again approximately two weeks before surgery. We evaluated the current screening and treatment of intranasal colonization with MRSA in our elective primary total hip arthroplasty (THA) patient population. Out of 6251 patients, 106 (1.7%) had nasal MRSA contamination. The bacteria were not eradicated in three (3.6%) patients at the second screening. Twenty-two joints (0.35%) out of the 6251 had deep infections. Only 1 patient out of the 106 MRSA nasal carriers suffered from PJI. Twenty-one of the 6145 non-carriers had PJI. The difference between the prevalence of nasal MRSA contamination and the incidence of deep infections was not statistically significant. Our findings suggest that screening of all patients for nasal MRSA before THA followed by mupirocin calcium treatment if needed is sufficient PJI prophylaxis.

Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty.

Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Stepwise implementation of an enhanced recovery pathway for elective total hip arthroplasty in a Swiss hospital: a cohort study.

Enhanced recovery programs after total hip arthroplasty have been shown to reduce hospital length of stay without compromising results, but yet there is a lack of data for the Swiss population. Therefore, this retrospective cohort study evaluated whether similar positive effects on clinical outcomes are present in the context of the Swiss healthcare system. Patients who underwent elective primary total hip arthroplasty were analysed. The baseline group comprised 50 patients treated consecutively by one surgeon in 2013 according to the clinical practice guidelines. Another surgeon implemented a new standardised treatment protocol in April 2014. In January 2018, this protocol was followed by an enhanced recovery program that integrated all care providers at the hospital. The data of the baseline group (series 0) and four series of 50 patients each, two treated with the standardised treatment protocol (series 1-2) and two treated with the enhanced recovery program (series 3-4), were analysed. All patients had follow-ups at 6 weeks and 3 months after surgery. The primary outcomes were length of stay and discharge destination; the secondary outcomes were admission on the day of surgery (instead of one day prior), the use of urinary catheters, the administration of opioids, the difference between pre- and postoperative haemoglobin, blood transfusions, and adverse events within 3 months of surgery. The median length of stay was 10 days in the baseline group and only 5 days after the implementation of the standardised protocol and enhanced recovery program in series 4 (p <0.001). The percentage of patients discharged directly home was higher in series 4 than in the baseline group (84% vs. 66%, p = 0.085). Patients admitted to the hospital on the day of surgery increased from 2% in series 0 to 98% in series 4 (p <0.001). The use of urinary catheters was significantly higher in the baseline group (100% of patients) than in series 3 and 4 (0%) (p <0.001), and the number of patients who did not require opioids was significantly higher in series 4 than in series 0 (36% vs. 10%, p = 0.007). The median blood loss (500 ml vs. 300 ml, p <0.001), median difference in pre- and postoperative haemoglobin (29 g/dl vs. 25 g/dl, p = 0.145), and number of blood transfusions (5 vs. 2 p = 0.99) were higher in the baseline group than in series 4. The number of adverse events did not differ significantly between groups (p = 0.699). Almost all parameters examined in this study showed improvement, whereas the rate of adverse events was not affected and remained low. The presented data can be used as a benchmark, but details of these findings need to be confirmed in larger cohorts.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty

BackgroundA shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution’s most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. MethodsA retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. ResultsOverall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. ConclusionsThe SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. Level of EvidenceIII.

Costs and Outcomes of Total Joint Arthroplasty in Medicare Beneficiaries Are Not Meaningfully Associated with Industry Payments.

Prior studies have demonstrated that industry payments affect physician prescribing patterns, but their effect on orthopaedic surgical costs is unknown. This study examines the relationship between industry payments and the total costs of primary total joint arthroplasty, as well as operating room cost, length of stay, 30-day mortality, and 30-day readmission. Open Payments data were matched across a 20% sample of Medicare-insured patients undergoing primary elective total hip arthroplasty (THA) (n = 130,872) performed by 7,539 surgeons or primary elective total knee arthroplasty (TKA) (n = 230,856) performed by 8,977 surgeons from 2013 to 2015. Patient, hospital, and surgeon-specific factors were gathered. Total and operating room costs, length of stay, mortality, and readmissions were recorded. Multivariable linear and logistic regression models were used to identify the risk-adjusted relationships between industry payments and the primary and secondary outcomes. In this study, 96.7% of THA surgeons and 97.4% of TKA surgeons received industry payments. After multivariable risk adjustment, for each $1,000 increase in industry payments, the total costs of THA increased by $0.50 (0.003% of total costs) and the operating room costs of THA increased by $0.20 (0.003% of total costs). Industry payments were not associated with TKA cost. Industry payments were not associated with 30-day mortality after either THA or TKA. Higher industry payments were independently associated with a marginal decrease in the length of stay for patients undergoing THA (0.0045 days per $1,000) or TKA (0.0035 days per $1,000) and a <0.1% increase in the odds of 30-day readmission after THA for every $1,000 in industry payments. The median total THA costs were $300 higher (p < 0.001), whereas the median TKA costs were $150 lower (p < 0.001), for surgeons receiving the highest 5% of industry payments. These surgical procedures were more often performed in large urban areas, in hospitals with a higher number of beds, with a higher wage index, and by more experienced surgeons and were associated with a 0.4 to 1-day shorter length of stay (p < 0.001). Although most arthroplasty surgeons received industry payments, a minority of surgeons received the majority of payments. Overall, arthroplasty costs and outcomes were not meaningfully impacted by industry relationships. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Can Dual Mobility Cups Reduce Revision and Dislocation Risks? An Analysis of 107,528 Primary Total Hip Arthroplasties in the United States

BackgroundDual mobility acetabular cups (DMC) were designed to increase the effective femoral head size and improve stability with the goal of reducing revision risk at the potential cost of polyethylene thickness. We sought to evaluate revision risk following primary elective total hip arthroplasty with DMC compared to highly cross-linked polyethylene (XLPE). MethodsA cohort study was conducted using data from a Kaiser Permanente’s total joint arthroplasty registry. Patients ≥18 years who underwent primary elective total hip arthroplasty using DMC, unipolar Metal-on-XLPE (MoXLPE), or unipolar Ceramic-on-XLPE (CoXLPE) were identified (2010 to 2021). The final sample comprised 2,219 DMC, 48,251 MoXLPE, and 57,058 CoXLPE. Multiple Cox proportional hazard regressions were used to evaluate aseptic revision and any dislocation regardless of revision within 6 years follow-up. ResultsIn adjusted analyses, no differences in aseptic revision risk were observed for MoXLPE (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 0.72 to 1.51) or CoXLPE (HR = 0.98, 95% CI = 0.69 to 1.40) compared to DMC. No differences in dislocation risk were observed for MoXLPE (HR = 1.42, 95% CI = 0.93 to 2.15) or CoXLPE (HR = 1.25, 95% CI = 0.84 to 1.87) compared to DMC. ConclusionsIn a US-based cohort, 6-year aseptic revision risk of DMC was similar to metal or ceramic femoral head unipolar constructs. Furthermore, no difference in dislocation risk was observed. Continued longer-term follow-up may reveal if there is a reduced risk of dislocation that comes at the cost of increased late revision. Level of EvidenceLevel III.

National variation in prophylactic antibiotic use for elective primary total joint replacement.

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance. The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital's website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance. The primary choice and dosing of the prophylactic antimicrobial regimens varied widely. The two most used regimens were combined teicoplanin and gentamicin, and cefuroxime followed by two or three doses of cefuroxime eight-hourly, recommended by 24 centres (22.02%) each. The alternative choice and dosing of the prophylactic antimicrobial regimen also varied widely across the 83 centres with data available. Prophylaxis regimens across some centres fail to cover the likeliest causes of surgical site infection (SSI). Five centres (4.59%) recommend co-amoxiclav, which confers no Staphylococcus coverage, while 33 centres (30.28%) recommend cefuroxime, which confers no Enterococcus coverage. Limited adherence to 2018 Philadelphia Consensus Guidance was observed, with 67 centres (61.50%) not including a cephalosporin in their guidance. This analysis of guidance on antimicrobial prophylaxis in primary arthroplasty across 109 hospitals and trusts in the UK has identified widespread variation in primary and alternative antimicrobial regimens currently recommended.