Elective Total Hip Replacement Surgery Research Articles

Individual Factors Modifying Postoperative Pain Management in Elective Total Hip and Total Knee Replacement Surgery.

Total hip and knee replacements are the most common orthopedic procedures performed due to osteoarthritis. Pain is an intrinsic symptom accompanying osteoarthritis, persisting long before surgery, and continuing during the preoperative and postoperative periods. Appropriate pain management after surgery determines the comfort, duration, and cost of hospitalization, as well as the effectiveness of postoperative rehabilitation. Individual differences in pain perception and tolerance in orthopedic patients remain an important research topic. Therefore, the aim of this study was to investigate the predictors of analgesic requirements (morphine, acetaminophen, and ketoprofen), including individual pain threshold and tolerance, body mass index (BMI), diabetes, and beliefs about pain control in patients undergoing elective hip or knee arthroplasty using a multilevel regression model (N = 147, 85 women, 62 men, 107 after hip replacement, and 40 after knee replacement). Results: Higher pain tolerance was associated with a lower dose of morphine per kg after surgery. Patients undergoing hip surgery received a lower dose of ketoprofen than patients undergoing knee surgery. The more the patient believed in personal pain control, the stronger the negative relationship between pain tolerance and morphine requirement. The lowest doses were given to patients with the highest pain tolerance and the greatest belief in personal control. Factors such as belief in pain control and pain tolerance should be considered in comprehensive postoperative pain management in orthopedic patients to reduce opioid doses and, thus, side effects.

Retention of Urine after Elective Total Hip and Knee Replacement Surgeries - A Literature review

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. 

The Accuracy of Digital Preoperative Templating in Primary Total Hip Replacements.

Background​ Digital templating is an essential part of preoperative planning in elective total hip replacement (THR) surgery. The goals of templating are to predict femoral and acetabular implant sizes, to assess leg length, offset, and implant positioning. Templating markers such as the KingMark device (Brainlab, Munich, Germany) have been developed to improve the accuracy. Although templating is commonly used in many centres, there are challenges related to the accuracy of the process, such as true magnification ideal positioning of the pelvis and hips/body habit (obesity). Objectives The aim of this study was to assess the accuracy of preoperative templating in THR patients, and to assess the difference between templating performed with and without the KingMark device. Methods​ Our retrospective study included 642 consecutive patients who had primary THR at the Royal Bournemouth Hospital in the UK. Four hundred fifty-three (71%) of patients had the KingMark device on their templated radiographs. Patients who had hybrid total hip replacements using an uncemented acetabular component and cemented femoral component were included in the study. Digital templating was done using TraumaCad software (Brainlab). Analysis of the accuracy of predicting component size has been evaluated by comparing preoperative planned sizes with implanted sizes as documented by the surgeons and labels attached to the operative note. ​ ​Results​ The templated size corresponded to the actual femoral implant used in approximately 65.2% of cases. When femoral prostheses within one size above or below the templated size were included,​the accuracy of preoperative templating rose to 97.2%. Regarding the uncemented acetabular component, the templated size corresponded to the actual acetabular implant used in 46.3% of cases. When acetabular cup within one size above or below the templated size were included, the accuracy of preoperative templating rose to 87.5%. Similarly, there was minimal difference between the predicted templated sizes using the KingMark device compared to templating performed without it. ​Conclusions​ Preoperative templating is an essential part in optimizing the outcome of THRs. Templating allows the surgeon to estimate the size of the components to be used. It also provides a starting point, from which the surgeon can proceed from, and saves valuable intraoperative time by assessing the level of the femoral neck osteotomy and the degree of lateral rasping. Multiple factors affect the accuracy of preoperative templating including the patient BMI, external rotation of the hip and surgeon's experience. Although there are different methods of templating, digital templating with 2D radiographs is likely the most cost-effective and efficient process available at this time.

[Outpatient care through cross-sector prehabilitation and rehabilitation concepts in outpatient hip and knee arthroplasty].

Kein noch so flammender Appell eines Gesundheitspolitikers hat alle Versorgungsstrukturen unseres Gesundheitssystems so zur Überprüfung eigener Effizienz und Einsparpotenziale gezwungen, wie das SARS-CoV‑2. Fast-Track-Chirurgie, lange vor der aktuellen Pandemie entwickelt, kann auch unter Einbindung verzahnter Versorgungsstrukturen ein unverzichtbares Element moderner Krankenhausroutinen werden. Durch deutlich kürzere Krankenhausverweildauern, sinkende Komplikationsraten sowie durch zusätzliche Stärkung der Eigenkompetenz und Motivation der betroffenen Patientinnen und Patienten, kann die Patientenzufriedenheit und das klinische Outcome verbessert werden. Krankenhauspersonal könnte entlastet und Gesamtkosten, auch durch Einbindung externer Prähabilitationszentren, gespart werden. Es gilt nun, weiter Standards zum Aufbau und zur Umsetzung entsprechend abgestimmter Prähabilitations- und Rehabilitationskonzepte bei geplanter endoprothetischer Versorgung von Hüft- und Kniegelenken zu entwickeln und idealerweise gleichzeitig Ressourcen durch regionale Vernetzung zu sparen.

Introducing Virtual Prehabilitation to a UK Elective Total Hip Replacement service to improve patient outcomes: An overview of the literature and proposed implementation plan

Elective Total Hip Replacement (THR) surgery is one of the most common elective surgeries in the UK, costing the National Health Service (NHS) over £300,000,000 annually. A review of the literature identified preoperative rehabilitation, known as ‘prehabilitation’, improves patient outcomes and decreases Length Of hospital Stay (LOS). This approach follows NICE guidelines which recommend prehabilitation for all patients undergoing joint replacement surgery. Challenges accessing prehabilitation classes at UK hospitals due to inadequate transport and COVID-19 restrictions present an opportunity to provide prehabilitation virtually. Physiotherapy services are increasingly utilising technology, in line with The NHS Long Term Plan to increase service accessibility. A review of the literature has established virtual prehabilitation is effective, feasible, and preferable for patients. Quality Improvement methodology has been used to propose an implementation plan for a virtual prehabilitation service. Further research is required to create a standardised prehabilitation protocol, and to assess the long-term effects and sustainability of virtual prehabilitation.

Soft-tissue thickness radiographic measurement: a marker to evaluate acute periprosthetic joint infection risk in total hip replacement.

The objective of our study was to evaluate the association between acute periprosthetic joint infection (APJI) and radiographic measurement of soft-tissue thickness in elective total hip replacement surgery. A case-control study was conducted to compare the soft-tissue thickness radiographic measurement (SRM) at the hip in patients diagnosed with APJI based on Tsukayama et al. (2003) criteria after total hip replacement with patients that were not infected, at a single institution from 2013 to 2019. To minimize selection bias, each case was matched with two controls using the following methodology: patients of the same sex, with an age variation of 5 years, and nearest in surgery date to the cases were selected. All postoperative radiographs were performed in the first 24 h after total hip arthroplasty (THA) surgery as it is protocolized in our institution. Soft-tissue thickness radiographic measurement was defined as the distance from the tip of the greater trochanter to the skin following a perpendicular line to the femoral diaphysis in postoperative anteroposterior hip radiographs. In total, 78 patients were included (26 cases and 52 controls). The SRM median of the cases was 76.19 mm (SD: 26.518) and 53.5 mm (SD: 20.47) in controls. A multivariate logistic regression model showed an independent association between APJI and SRM (odds ratio (OR)  1.033, 95 % confidence interval (CI) 1.007–1.059, .012). Patients with an SRM greater than 60 mm had a 7-fold increase in the odds of APJI (OR  7.295, 95 % CI  2.364–22.511, .001). The results of our study suggest an association between large SRM at the hip and the risk of APJI in patients with primary total hip arthroplasty. SRM may be a helpful and easy tool for evaluating the risk of APJI before elective primary total hip replacement surgery.

Safety of apixaban in Indian patients undergoing elective total knee replacement or total hip replacement surgery: A multi-center, phase-IV study.

Background:Venous thromboembolism is a significant source of morbidity and mortality following total hip replacement and total knee replacement. Apixaban has been proven to be efficacious without increased risk of bleeding in phase-III trials in patients undergoing total knee replacement and total hip replacement. Due to paucity of data on safety of apixaban in Indian patients, this phase-IV study was conducted to evaluate safety of apixaban in patients undergoing total knee replacement and total hip replacement.Methods:In this non-comparative phase-IV clinical trial, patients undergoing elective total knee replacement or total hip replacement surgery, or a revision of at least one component of total knee replacement or total hip replacement, were enrolled. The eligible patients were given the approved dosage of apixaban 12 to 24 h after completing the skin wound closure. The primary safety outcome was the composite of the International Society on Thrombosis and Haemostasis–defined major bleeding and clinically relevant non-major bleeding events at the end of the treatment. The secondary efficacy endpoint was the composite of venous thromboembolism/all-cause death at the end of the treatment.Results:A total of 498 patients received apixaban prophylaxis therapy. Six (1.2%) bleeding adverse events were observed during the treatment period. Only one bleeding event was adjudicated as an International Society on Thrombosis and Haemostasis–defined clinically relevant non-major bleeding event (moderate severity). There were no fatal bleeding events and no deaths following the treatment. One venous thromboembolism event, that is, symptomatic distal left leg DVT, was reported in a total knee replacement patient and was adjudicated during the treatment period.Conclusion:Apixaban demonstrated a favorable safety profile for venous thromboembolism prevention in Indian patients undergoing total knee replacement or total hip replacement.

Incidence and Associated Risk Factors for Falls in Older Adults Postdischarge Who Undergo Elective Total Hip Replacement Surgery-A Prospective Cohort Study.

Hip replacement surgery improves health-related quality of life; however, it has been suggested that falls rates increase after hospital discharge. The aim of the study was to determine the incidence and associated risk factors for falls in older adults in the 12 months after undergoing elective total hip replacement surgery. A prospective observational cohort study was conducted. Participants were adults aged 60 years or older who underwent primary elective total hip replacement surgery in a private tertiary hospital in Perth, Australia. Baseline data collected immediately prior to discharge included use of walking aids, medications, and functional level of independence (using Katz and Lawton scales). Falls data were collected for 12 months using calendars and monthly phone calls. Data were analyzed using logistic and negative binomial regression modeling. Participants' ([n = 167], 54.4% female) mean age was 71.2 (±6.9) years. There were 51 (31%) participants who used a walking aid prior to surgery. There were 140 falls reported over 12 months by 67 (42%) participants, of which 90 (64.3%) were injurious (n = 9 fractures). The fall rate was 2.6 per 1000 patient-days. Age (adjusted odds ratio 1.10, 95% confidence interval 1.01-1.20) and hospital length of stay (adjusted odds ratio 1.24, 95% confidence interval 1.00-1.54).were significantly associated with sustaining multiple falls. More than 40% of older adults fell in the 12 months after elective hip replacement surgery although the cohort had low fall risk prior to surgery. Rehabilitation after hip replacement surgery should consider fall prevention.

Preoperative Anemia and Blood Transfusion Requirement during Hip Surgery: Synthetic and Real Patient Cohort Data

Introduction: Blood transfusion (BT), albeit lifesaving, is associated with morbidity, mortality and increased hospitalization length. In the last decade, due to BT-related risks the "patient blood management" (PBM) approach has been introduced to clinical practice. PBM focuses on multidisciplinary and multimodal preventive measures aiming to reduce the need for transfusions and ultimately improve patients' clinical outcomes. The 1st pillar of PBM is optimizing the red blood cell mass. Preoperative anemia is prevalent in approximately 25% of the patients undergoing elective total hip replacement surgery. The indications for BT during orthopedic surgery include excessive bleeding or hemodynamic instability and not the hemoglobin (Hb) level. Several studies have shown that preoperative anemia is a risk factor for postoperative complications. Strategies to minimize BT requirement during surgery have mainly focused on lowering transfusion thresholds. Randomized controlled trials have shown that in most clinical scenarios, a restrictive transfusion threshold (Hb level 7-8g/dL) appears to be non-inferior to the liberal transfusion strategy in terms of blood use, morbidity and mortality. Other strategies have not been fully evaluated. We hypothesize that preoperative anemia may lead to redundant blood product use with its inherent complications during elective orthopedic surgery. Methods: Medical files of patients who underwent hip surgery between 2011-2018 at the Rambam Health Care Campus, a tertiary care center in Northern Israel, were reviewed. Data on patient demographics, clinical findings, comorbidities, surgery type, hospitalization length were retrieved. Patients with available Hb level measurements within 90 days pre-surgery were included in the study. Receiving >1 blood unit was considered a surgery complication and such patients were excluded. We created a synthetic data cohort using MDClone Healthcare Data Sandbox. MDClone is an environment enabling fast data extraction and producing synthetic data for analysis that does not require IRB approval. Upon confirming the feasibility of using the synthetic data and receiving IRB approval, data of real patients were compared with those of the synthetic cohort. To track significant differences group means were analyzed using ANOVA followed by Tukey HSD. Results: During the evaluated period, 976 patients underwent elective hip surgery; 383 were excluded from the analysis due to receipt of >1 blood unit or lack of Hb value. Data on 593 patients [women: n=360 (60%)] were included in the final analysis. During surgery, BT was required in 29 % of patients, with this need being slightly higher among women (31.1% vs. 26.6%; p =NS). Patients receiving BT had a significantly lower mean Hb level than those who did not require it (11.94g/dL versus 12.8g/dL for women and 12.3g/dL vs. 13.8g/dL for men; p <0.001). Hospitalization was longer in transfused patients compared to non-transfused ones (mean 7.5 vs. 6.9 days, p =0.018) and in patients with a low Hb level (female <12, male <13.5) than in those with a high Hb level, irrespective of BT receipt (p <0.00045). Patients with at least one of the following diagnoses were significantly more likely to have a lower preoperative Hb level (p <0.05): diabetes, renal failure, ischemic heart disease. No other factors (e.g., patient's weight, red cell distribution width or blood pressure) were predictive of transfusion need. The probability of transfusion of 1 blood unit was 0.43 in the Hb 11g/dL cohort and 0.15 in Hb 13g/dL cohort (35% reduction). Results of real and synthetic data groups are presented in figures 1A & 1B. All differences in mean values between the two datasets were insignificant (p close to 1). Conclusions: Preoperative anemia in patients undergoing elective hip surgery is a risk factor for BT requirement and longer hospitalization. Diagnosis and management of anemia using timely pre-surgery evaluation may minimize intraoperative BT, particularly in women and patients with comorbidities and may shorten the hospitalization length. Synthetic data provide an accurate prediction of real data results. Disclosures No relevant conflicts of interest to declare.

For which patients is attending a pre-operative education session most important in a total hip and knee replacement eras pathway?

Objectives: Optimising the psychological status of patients’ pre-surgery through education is recommended by the Enhanced Recovery after Surgery (ERAS) Society. However, despite this; the majority of the current evidence base does not confirm that preoperative education reduces length of stay in total hip or knee replacement pathways. The aim of this study is to compare length of stay between patients who attended an education class prior to elective total hip or knee replacement surgery, compared to those who did not

Advocacy for use of the modified Iowa Level of Assistance Scale for clinical use in patients after hip replacement: an observational study

ObjectivesTo test the internal consistency and item difficulty of the modified Iowa Level of Assistance Scale (mILAS). DesignRetrospective observational study. SettingTwo orthopaedic wards of two general hospitals. ParticipantsFollowing elective primary unilateral total hip replacement surgery, all participants performed mILAS activities that were scored daily to assess their recovery of activities during hospitalisation. Main outcome measuresThe internal consistency and the level of assistance needed by the patient (item difficulty) of the mILAS were calculated using data from Deventer Hospital, Deventer, the Netherlands (n=255). A cross-validation was performed using data from Nij Smellinghe Hospital, Drachten, the Netherlands (n=224). ResultsThe internal consistency of the mILAS was acceptable on all three postoperative days (α=0.84 to 0.97). Cronbach’s α and Rasch analysis revealed a misfit of stair climbing with the other items of the mILAS. The item difficulty of the mILAS items changed over the first two postoperative days. During the first three postoperative days, the sit to supine transfer was generally the most difficult item to achieve, and the sit to stand transfer was the least difficult item to achieve as rated by physiotherapists. The cross-validation analysis revealed similar results. ConclusionsThe mILAS is a clinically sound measurement tool to assess the ability of patients to perform five functional tasks safely during hospitalisation. Stair climbing appears to be the easiest item to complete, and the sit to supine transfer is generally the most difficult after surgery.

Resource use and costs associated with opioid-induced constipation following total hip or total knee replacement surgery.

PurposeConstipation is a well-known complication of surgery that can be exacerbated by opioid analgesics. This study evaluated resource utilization and costs associated with opioid-induced constipation (OIC).Patients and methodsThis retrospective, observational, and propensity-matched cohort study utilized the Premier Healthcare Database. The study included adults ≥18 years of age undergoing total hip or total knee replacement as inpatients who received an opioid analgesic and were discharged between January 1, 2012, and June 30, 2015. Diagnosis codes identified patients with OIC who were then matched 1:1 to patients without OIC. Generalized linear and logistic regression models were used to compare inpatient resource utilization, total hospital costs, inpatient mortality, and 30-day all-cause readmissions and emergency department visits.ResultsOf 788,448 eligible patients, 40,891 (5.2%) had OIC. Covariates were well balanced between matched patients with and without OIC (n=40,890 each). In adjusted analyses, patients with OIC had longer hospital lengths of stay (3.6 versus 3.3 days; p<0.001), higher total hospital costs (US$17,479 versus US$16,265; p<0.001), greater risk of intensive care unit admission (odds ratio [OR]=1.12, 95% CI: 1.01–1.24), and increased likelihood of 30-day hospital read-missions (OR=1.16, 95% CI: 1.11–1.22) and emergency department visits (OR=1.38, 95% CI: 1.07–1.79) than patients without OIC. No statistically significant difference was found with inpatient mortality (OR=0.89, 95% CI: 0.59–1.35).ConclusionOIC was associated with greater resource utilization and hospital costs for patients undergoing primarily elective total hip or total knee replacement surgery. These results support OIC screening and management strategies as part of perioperative care management.

Introduction of ‘Enhanced Recovery’ to patients undergoing elective total hip and knee replacement surgery

Purpose: The 2009–2012 Department of Health ‘Enhanced Recovery Partnership Programme’ documents that enhanced recovery (ER) of those patients undergoing elective primary total hip replacement (THR) and primary total knee replacement (TKR) surgery should include pre-operative assessment/education; and early mobilisation in the post-operative period (Simpson et al., 2015).

Thromboprophylaxis with enoxaparin and direct oral anticoagulants in major orthopedic surgery and acutely ill medical patients: a meta-analysis.

Subjects undergoing major orthopedic surgery and acutely ill hospitalized medical patients represent a population at medium-high risk for venous thromboembolism (VTE). They are treated with low molecular weight heparin (LMWH) and direct oral anticoagulants [DOACs] for VTE prevention. We conducted a meta-analysis of phase III randomized clinical trials evaluating LMWH enoxaparin versus DOACs for prophylaxis of VTE by combining studies including patients undergoing elective total hip and knee replacement surgery, and acutely ill hospitalized medical subjects. Studies were searched using PubMed, MEDLINE, and EMBASE databases until December 2016. Differences in clinical outcomes for efficacy and safety endpoints between treatment groups were expressed as risk differences with 95% confidence intervals (95% CI), using random effects regression models. Fourteen RCTs were considered (60,467 subjects). Overall mortality, symptomatic deep venous thrombosis, non-fatal pulmonary embolism (PE) major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) are not different between treatment regimens. Treatment with LMWH enoxaparin is associated with a lower risk of fatal PE plus VTE-related death compared therapy with DOACs (RD=0.040%, 95% CI 0.001-0.080%, p=0.0434). Subgroup analysis shows an incidence of MB (RD=0.181%, 95% CI 0.029-0.332%, p=0.0033) and CRNMB (RD=0.546%, 95% CI 0.009-1.082%, p=0.0462) in patients treated with 40mg OD enoxaparin compared to DOACs. In major orthopedic surgery and acutely ill hospitalized medical patients, DOACs do not offer clear advantages in terms of clinical efficacy compared to enoxaparin. The advantage of the latter in terms of major and CRNMB, when used at a dose of 40mg, is statistically significant, but small in terms of clinical relevance.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Visits to the Emergency Department After Joint Replacement: Commentary on an article by Micaela A. Finnegan, BA, et al.: "Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care".

Visits to the Emergency Department After Joint Replacement: Commentary on an article by Micaela A. Finnegan, BA, et al.: "Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care".

Parecoxib Supplementation to Morphine Analgesia Decreases Incidence of Delirium in Elderly Patients After Hip or Knee Replacement Surgery: A Randomized Controlled Trial.

Severe pain and high-dose opioids are both associated with increased risk of postoperative delirium. The authors investigated whether parecoxib-supplemented IV morphine analgesia could decrease the incidence of delirium in elderly patients after total hip or knee replacement surgery. In a randomized, double-blind, 2-center trial, patients of 60 years or older who underwent elective total hip or knee replacement surgery were assigned in a 1:1 ratio to receive either parecoxib (40 mg at the end of surgery and then every 12 hours for 3 days) or placebo (normal saline). All patients received combined spinal-epidural anesthesia during surgery and IV morphine for postoperative analgesia. The primary outcome was the incidence of delirium within 5 days after surgery. Between January 2011 and May 2013, 620 patients were enrolled and were included in the intention-to-treat and safety analyses. The incidence of delirium was significantly reduced from 11.0% (34/310) with placebo to 6.2% (19/310) with parecoxib (relative risk 0.56, 95% confidence interval 0.33-0.96, P = .031). The severity of pain and the cumulative consumptions of morphine at 24, 48, and 72 hours after surgery were significantly lower with parecoxib than with placebo (all P < .001), although the differences were small. There was no difference in the incidence of postoperative complications between the 2 groups (12.3% [38/310] with placebo versus 11.6% [36/310] with parecoxib; P = .80). For low-risk elderly patients undergoing elective total hip or knee replacement surgery, multidose parecoxib supplemented to IV morphine decreased the incidence of postoperative delirium without increasing adverse events.

Pharmacoeconomic study on rivaroxaban vs conventional venous thromboembolism prophylaxis following elective total hip or knee replacement surgery in Serbia: Single centre study

Introduction: Venous thromboembolism (VTE) is often clinically unobservable, showing the first symptoms only after the patient has been discharged from the hospital, owing to which symptoms may not be recognized in time and serious complications may arise after hip or knee replacement surgery. The outcome for a patient who has had a symptomatic episode of VTE may be bad due to a risk of recurrent VTE and the development of postthrombotic syndrome. The annual incidence of VTE is around 80-180 cases in 100.000, based on population studies. Worldwide, orthopaedists and anaesthesiologists mostly refer to ACCP guidelines from America, or guidance from NICE and Scottish Medicines Consortium in Europe. All the guidelines include rivaroxaban as a therapy of choice for the prevention of VTE following elective arthroplasty as the therapy with rivaroxaban has shown both effectiveness and cost-savings. Many countries have included rivaroxaban as a medicine of first choice in the therapy for the above described indication. Aim: The objective of this analysis is to demonstrate cost-effectiveness of the new therapy with rivaroxaban versus conventional in VTE prophylaxis for patients undergoing elective hip or knee replacement surgery. Methodology: This paper is a part of the academic IV phase pharmacoecconomic study using extrapolation datas (RECORD 1, RECORD 2, RECORD 3) done in Serbia as single center expirience of Institute for Orthopaedic Surgery 'Banjica', in 2015. Information on drug prices, basic pharmacological characteristics, and on services of health institutions, are taken from the List of Drugs and Pricelist of the Republic Health Insurance Fund, as well as the Thromboembolism Prophylaxis Guide of the Institute 'Banjica'. The Incremental cost-effectiveness ratio (ICER) and Cost-utility analysis (CUA) have also been used in relation to the Quality-adjusted life-year (QALY). Furthermore, in the calculation the proposed price of a defined daily dose (DDD) of rivaroxaban was 3.36 EUR. Results: Total savings obtained annually through the application of rivaroxaban instead of usual prophylaxis (6,900 surgeries) could lead to cost savings of EUR 511,248.35 with the ICER value shows that therapy with rivaroxaban is dominant. Conclusions: The introduction of rivaroxaban in the therapy will enable patients to receive more conformable oral therapy with the same amount of health insurance resources spent, while on the other hand significant savings will be obtained owing to a decrease in the number of inpatient days in hospitals, as well as owing to the fact that regular control examinations of INR and number of blood platelets will not be necessary, which otherwise may amount to EUR 511,248.35annually for the said indication. The authors suggest support for the IV phase of the investigator initiated academic clinical trials with the intention of gaining security and personal experiences of doctors who use rivaroxaban in clinical practice.

The relationship between the use of cement during total hip replacement and blood pressure values

Background Total hip replacement is a common orthopaedic procedure associated with an elevated cardiovascular risk. There are several methods for total hip replacement, including whether or not to use cement for the prosthesis fixation. The aim of the study was to compare clinical characteristics, including blood pressure, in patients undergoing total hip replacement with and without the use of cement. Material and methods The study included patients with elective total hip replacement surgery, who were divided into those in whom the procedure was performed with or without the use of medical cement. The criteria for using cement were assessed during operation by the operator, according to the current protocol. All patients were interviewed, screened, and had their medical records checked for the prior diagnosis of cardiovascular risk factors. Blood pressure values were measured before and after the procedure according to the current guidelines. Results The study population consisted of 65 patients in whom the total hip replacement was performed (mean age 61.5 ± 15.0 years; 50.8% male). 60% of patients had the hip replacement without cement and 40.0% had a procedure with the use of cement. Patients in whom the cement was used were significantly older (75.0 ± 8.5 vs. 53.0 ± 11.5 years; p < 0.0001) and more often diagnosed with arterial hypertension (61.5 vs. 33.3%; p = 0.04), than those in whom it was not used. Systolic blood pressure values were significantly higher before and after the procedure (138.8 ± 18.2 vs. 130.8 ± 21.5 mm Hg, p = 0.04; 122.6 ± 13.3 vs. 113.8 ± 14.1 mm Hg, p = 0.03; respectively) in the group which required cement. Conclusions Patients with hip replacement using cement have higher systolic values before, and after the surgery than in patients in whom cement wasn’t used. Therefore careful management and risk assessment is especially important in patients receiving the total hip replacement with the use of cement.

A clinical audit of the utilisation of red cell products in elective total hip replacement surgery.

Previous studies have documented a marked variation in transfusion practice for total hip replacement (THR) surgery. To audit red cell product utilisation for THR at two Western Cape tertiary referral hospitals (HY and HG). The folders of 207 consecutive patients undergoing elective THR surgery from January 2013 to December 2013 were reviewed. Information relating to age, sex, clinical observations, indications for surgery, pre- and postoperative haemoglobin (Hb) values, comorbidities, length of hospital stay and transfusion history was recorded. The transfusion rate at HY (41.6%) was significantly higher than that at HG (10.0%). The mean postoperative Hb in the transfused patients at HG was 8.3 g/dL v. 9.1 g/dL at HY. Females had a significantly higher transfusion rate (33.0%) than males (15.0%) (p&lt;0.05), and the mean age of transfused patients was significantly greater than that of untransfused patients (p&lt;0.005). Although patients with comorbidities had a higher transfusion rate than those without, this did not reach statistical significance. Of 120 patients with complete data, 113 (94.2%) had a blood bank order, of which the vast majority, 102/113 (90.3%), were group-and-screen (G&amp;S) requests; 29/113 (25.7%) were converted to a full crossmatch. Overall, the transfusion rate for both hospitals was 25.8%, which is well within published rates. A guideline Hb trigger of 8.0 g/dL is recommended as per published guidelines, with the caveat that the clinical judgement of the attending clinician whether a transfusion is indicated is paramount. Causes of preoperative anaemia should be investigated and treated. Routine cross-matching preoperatively is unnecessary, and a G&amp;S order is sufficient.