Elective Total Knee Replacement Research Articles

¿Son las escalas de valoración de fragilidad superiores a la escala de valoración ASA en la predicción de complicaciones, estancia hospitalaria y readmisiones en prótesis total de rodilla? Un estudio comparativo entre pacientes octogenarios y septuagenarios

Background and objectiveFrailty scores have not been standardized for the preoperative assessment of patients undergoing total knee replacement (TKR). The aim of this study was to compare the efficacy of the American Society of Anesthesiology (ASA) score, the Charlson comorbidity index (ICC) and the simple frailty score (SSF) in predicting complications, hospital stay, readmissions and mortality after elective TKR. Materials and methodsWe retrospectively studied 448 patients who underwent TKR for osteoarthritis at our institution between 2016 and 2019. They were divided into two groups: Group A (263 patients, <80 years) and Group B (185 patients, >80 years).). All were classified by ASA, ICC and SSF scores. ResultsThe ICC was higher in Group B (median 5 [RI: 4-6] vs. 4 [RI: 3-5]; P<.001); however, it was not associated with a higher number of complications. When performing a logistic regression analysis we found, for complications: OR SSF=0.67, ICC=1.11; ASA 3 & 4=0.89 and age=1.04; while for readmissions: OR SSF=2.09; ICC=1.01; ASA 3 & 4=0.79 and age=1. ConclusionsThe ICC and SSF scales showed no differences to the ASA scale in the prediction of readmissions, complications and hospital stay. However, the SSF seems to have a better correlation in predicting unplanned readmission.

AB081. SOH23ABS_016. Is total knee replacement surgery warranted in the obese patient: a systematic review

Background: Obesity is a well-documented risk factor for the development of osteoarthritis. This in turn results in an increase in the need for joint replacement surgery amongst this cohort. The debate persists as to whether obese patients undergoing total knee replacement (TKR) surgery will experience a higher rate of complications. This has resulted in patients with obesity to be deemed unsuitable for elective TKR surgery.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Comparison of dural puncture epidural approach versus conventional epidural approach for anesthesia in patients undergoing total knee arthroplasty: Prospective randomized study

Background: Epidural anesthesia reduces the exposure to other anesthetics and analgesics. The dural puncture epidural (DPE) approach improves caudal spread of analgesia compared with epidural (EPL) approach without the side effects observed with the combined spinal EPL method. The goal of this work was to evaluate the efficacy of DPE method versus standard EPL method as an anesthetic method in cases undergoing Total Knee Arthroplasty (TKA). Methods: This prospective randomized double blinded study was carried out on 70 cases admitted for elective total knee replacement surgery. Cases were subdivided in to two equal groups: group I (EP): received fifeteen millilitres of (0.25% plain bupivacaine and 50 µg fentanyl) over 5 min., there was no dural puncture in this group and group II (DPE): who received fifeteen millilitres of (0.25% plain bupivacaine and 50 µg fentanyl) over 5 min., administered in the epidural space by epidural catheter at L3-L4 interspace, a dural puncture was created. All cases were assessed for time of onset of motor block, duration, number of top-up doses for 24 hours postoperative and adverse events. Results: There was significant decrease in mean value of time till sensory block and time till motor block occurred in group II versus group I (p value <0.001). there was significant decrease in mean value of Breen Modified Bromage scale in group II (p value <0.05) at 5min and 8min versus group I. Intergroup comparison of duration from administration of block till first top up dose and number of top up doses revealed no difference between two approaches. Conclusions: DPE method seemed to have faster onset of sensory and motor block versus standard EPL method.

Barriers, enablers and acceptability of home-based care following elective total knee or hip replacement at a private hospital: A qualitative study of patient and caregiver perspectives.

To facilitate implementation of home-based care following an elective total knee or hip replacement in a private hospital, we explored patient and caregiver barriers and enablers and components of care that may increase its acceptability. Thirty-one patients (mean age 71 years, 77% female) and 14 caregivers (mean age 69 years, 57% female) were interviewed. All themes were developed using thematic analysis, then categorised as barriers or enablers to uptake of home-based care or acceptable components of care. Barrier and enabler themes were mapped to the Theoretical Domains Framework. Eight themes emerged as barriers or enablers: feeling unsafe versus confident; caregivers' willingness to provide support and patients' unwillingness to seek help; less support and opportunity to rest; positive feelings about home over the hospital; certainty about anticipated recovery; trusting specialist advice over family and friends; length of hospital stay; paying for health insurance. Five themes emerged as acceptable components: home visits prior to discharge; specific information about recovery at home; one-to-one physiotherapy and occupational therapy perceived as first-line care; medical, nursing and a 24/7 direct-line perceived as second-line care for complications; no one-size-fits-all model for domestic support. Theoretical domains relating to barriers included emotion (e.g., feeling unsafe), environmental context and resources (e.g., perceived lack of physiotherapy) and beliefs about consequences (e.g., unwillingness to burden their caregiver). Theoretical domains relating to enablers included beliefs about capabilities (e.g., feeling strong), skills (e.g., practising stairs), procedural knowledge (e.g., receiving advice about early mobility) and social influences (e.g., caregivers' willingness to provide support). Multiple factors, such as feeling unsafe and caregivers' willingness to provide support, may influence implementation of home-based care from the perspectives of privately insured patients and caregivers. Our findings provide insights to inform design of suitable home-based care following joint replacement in a private setting.

INDISCRIMINATE COAGULATION TESTING FOR BLEEDING RISK ASSESSMENT PRIOR TO ORTHOPEDIC SURGERY. IS IT A RATIONAL APPROACH?

Abstract Objective: Indiscriminative preoperative coagulation testing to identify patients at risk of bleeding is commonly practiced. However, this practice is no longer supported by current recommendations. We conducted this study with an aim to evaluate the advantage of doing screening testing for coagulation and hemostasis in unselected patients prior to elective orthopedic surgeries in our setting. Material and Methods: It was a retrospective, cross sectional study carried out at Medicare Cardiac and General Hospital, Jinnah Medical and Dental College, Karachi. All the patients admitted for elective orthopedic bilateral total knee replacement and Hip replacement surgeries from March 2016 to December 2018 were included in the study. Electronic data of patients’ pre-operative test results for Prothrombin time, activated partial Thromboplastin time was retrieved. Frequency of patients with deranged coagulation screening was calculated. Results: A total of 367 patients underwent pre-surgical coagulation testing. Male to female ratio was 1:3. Median age of patients was 61±5 years. A total of 2.9% (n=11) patients were found to have deranged coagulation profile. Out of which 3 patients did not undergo surgery and were loss to follow up. Out of total 0.54% (n=2) patients had both prolonged PT and APTT, 1.6% (n=6) patients had prolonged APTT and 0.3% (n=1) patient experienced intraoperative bleeding requiring one unit of packed cell transfusion. Only 0.3% (n=1) patient experienced post-operative bleeding and dropped her Hemoglobin and received transfusion. Conclusion: The overall results of the study suggest that indiscriminate coagulation screening does not provide any additional information unless further detailed hemostatic evaluation is carried out. It is suggested that routine screening tests should not be performed unless a medical history is indicative of bleeding tendency. Key Words: Coagulation screening, Bleeding risk, Orthopedic surgery.

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.

The Association between Two-Stage Tourniquet Application during Total Knee Replacement and Blood Loss: A Retrospective Cohort Study.

Tourniquet use during total knee arthroplasty improves the surgical field, but is associated with several complications. The medical records of 506 patients who underwent elective total knee arthroplasty or total knee replacement from January 2017 to December 2020 were reviewed. A total of 331 patients who had undergone total knee arthroplasty were included. In the first half course group, the tourniquet was inflated with a pressure of 300 mmHg after manual banding before the incision and deflated after cement insertion. In the two-stage group, the tourniquet was inflated and deflated at the same stages of the procedure as in the first half course group. However, in this second group, the tourniquet was deflated for 15 min and then inflated again, and, finally, it was deflated after skin closure. The estimated blood loss, the number of patients who needed medications to control their blood pressure, and opioid usage at the post-anesthesia care unit were similar in both groups. The two-stage tourniquet technique was not related to reduced total blood loss in total knee arthroplasty.

Scaling up Quality Improvement for Surgical Teams (QIST)\u2014avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS

BackgroundThe aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement.MethodsWe undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019.Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative.ResultsThere were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52–2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42–2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively.ConclusionsQuality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS.Trial registrationProspectively registered on 15 February 2018, ISRCTN11085475

Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol

IntroductionMore than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%–0.5% fatal PE, and over 1000...

Tuberculosis Screening via Chest X-Ray is Financially Burdensome in Previously Independently Living Elective Total Knee Arthroplasty Patients.

BACKGROUNDIn 1995, to reduce the transmission of Tuberculosis (TB) the Centers for Disease Control and Prevention recommended that all patients discharged from hospitals be required to have chest x-rays (i.e., radiography) performed before admission to long term care facilities (LTCFs). Previously independently living patients (PILPs) who undergo elective total knee replacement (TKA) surgery are a population at higher risk to end up in LTCFs for rehabilitation. By 2017, the incidence of TB was 9,105 cases compared to 22,762 in 1995. However, the recommendations that hospitals be required to perform a chest x-ray in all patients (including PILPs) being transferred to LTCF’s have remained in place. The purposes of this study were to: a) determine the incidence of TB-positive chest x-rays in PILPS discharged to LTCFs after undergoing elective TKA surgery, and b) assess the cost (i.e., both financial and possible exposure to unnecessary radiation) of mandated chest x-rays before hospital discharge to LTCF for PILPs.METHODSRetrospective 2012-2017 patient chart data were collected from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to identify all elective TKAs for PILPs performed at two Ascension participating centers. Study data included sex, age, body mass index (BMI), length of stay, comorbidities, and chest x-ray results before discharge. Patients who underwent surgery for fracture, infection, trauma, or malignancy were excluded from the study. Categorical data were analyzed using Fisher’s exact test and Student’s t-test were used for continuous data.RESULTSThe authors identified 4,041 total elective TKA’s, from which 500 PILPs were discharged to a LTCF due to functional, medical and/or social concerns. Chest x-rays were associated with 500 (100%) negative findings for TB. Overall hospital costs for chest x-rays for patient’s being discharged to an extended care facility totaled $90,848.CONCLUSIONSThe mandated use of chest x-rays for TB screening of PILPs undergoing elective surgery TKA prior to discharge to LTCFs appear to place an unnecessary financial burden on the healthcare system. The mandatory use of x-rays for assessment of possible TB infection before transfer to LTCFs appears to also expose PILPs unnecessarily to radiation. Although further studies are needed to verify these results, the authors recommend that perhaps instead chest x-rays should be reserved for patients with specific comorbidities (e.g., patients on immunosuppressive therapy, with HIV, etc.) or for those patients residing in LTCFs prior to surgery.

Can introducing a direct endocrine pathway reduce hyponatraemia in elective knee and hip replacements? A closed-loop audit and service evaluation study.

Hyponatraemia 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. Day 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. Hyponatraemia 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). This 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. This 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.

Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial.

Introduction: Total knee arthroplasty (TKA) is a life-changing joint surgery that improves health-related quality of life and functional status. Patients in need of this surgery mostly belong to the geriatric age group with limited functional reserves and multiple co-morbidities requiring utmost perioperative care with the most suitable analgesic modalities. Regional analgesia (RA) should provide effective analgesia while allowing early mobility, reduced opioid consumption, and early discharge. Dual subsartorial block (DSB) is a novel procedure-specific, motor-sparing, and opioid-sparing RA technique for TKA surgeries. Our study compared the analgesic efficacy of the two different combinations of volumes used in DSB.Methods: This prospective randomized comparative study included patients between 25-75 years of age of American Society of Anesthesiology (ASA) I-II grades who underwent an elective cemented unilateral total knee replacement performed via medial approaches under neuraxial anesthesia. A total of 104 patients were divided into two equal groups based on the local anesthetic (LA) volumes (Group A 10/20 ml and Group B 20/10 ml) used in the DSB. Postoperative pain scores (using a visual analog scale) and quadriceps strengths (using neurological exam), and opioid consumption were measured at regular intervals till discharge.Results: Most patients (71.2%) remained pain-free and comfortable until discharge, while 28.8% complained of pain within 12 hours of DSB. Mean quadriceps strength remained almost normal (4-5/5) until the discharge with no incidences of buckling or fall in either group. Over time, the postoperative trend between the groups showed a significant difference for dynamic pain (p = 0.002) and quadriceps strength (p = <0.001). There was an insignificant difference (p = 0.161) between the groups regarding opioid consumption, with the median oral morphine equivalent of zero in both groups. Discussion: The effective analgesic coverage of DSB is based on the involvement of all innervations of the procedure-specific pain generators of TKR surgeries. The specific focus on selective sensory innervations and the type/volume of the LA used makes DSB a motor-sparing RA alternative that facilitates early mobility and discharge. It can provide effective postoperative analgesia without compromising the motor strength of the quadriceps muscle when administered in either 10/20 or 20/10 volumes.

Comparative Study Between Ultrasound Guided Femoral Nerve Block Versus Ultrasound Guided Saphenous Nerve Block After Total Knee Replacement

Abstract Background Total knee arthroplasty (TKA) is one of the most commonly performed operations in our daily practice. It is indicated in all patients with severe osteoarthritis and it needs early postoperative ambulation to improve postoperative outcomes and to reduce immobility related complications. Providing adequate analgesic control is very important to achieve functional recovery, facilitates rehabilitation and attenuates the progression from acute to chronic postsurgical pain, aiming to maximize non-opioid analgesics in addition to regional analgesic techniques. It is estimated that the majority of patients experience either severe pain (60% of patients) or moderate pain (30% of patients) following TKA surgeries. With the emergence of enhanced recovery after surgery ERAS clinical pathways, many surgical specialties are adopting multimodal analgesic regimens to improve patient outcomes. Objective This study aimed at shedding lights on the value of preserving the motor function in the immediate postoperative period after total knee replacement. That was illustrated by comparing femoral nerve block (mixed motor and sensory nerve) versus saphenous nerve block (pure sensory nerve) in the adductor canal, and the effect of either blocks on the analgesia and ambulation of the patients postoperatively. Patients and Methods After approval of the departmental ethical committee, from September 2017 to September 2019, this Prospective double armed interventional randomized clinical study was conducted at Ain Shams University Hospitals, operating theatre department on 40 adult patients of ASA physical status classification I-II, admitted to Ain Shams university hospital, scheduled for elective primary unilateral total knee replacement surgery. The patients were subdivided into 2 groups A and B, (20) patients for each group. Results In our study we performed a prospective randomized trial to compare between saphenous nerve block (adductor canal block ACB) versus femoral nerve block FNB regarding postoperative analgesic efficacy in terms of pain scores using visual analogue scale VAS during rest and during 45 degree passive flexion of the knee joint, both were measured at 6, 12, 24 and 48 hours postoperatively. Total nalufen consumption in the first 24 hours postoperative was measured in milligrams. Also postoperative Quadriceps muscle strength clinical testing by using a Timed Up-and-Go test (TUG test) at 24 hours postoperative and (10 minutes walking test) at 24 hours postoperative. We found that analgesic efficacy of both groups in the terms of VAS pain scores and cumulative 1st 24 hours Nalufin consumption are equivalent but there is a statistically significant difference in quadriceps muscle strength being higher in adductor canal block group than femoral nerve block group. TUG test results were lower in ACB group compared to FNB group, and results of 10-minutes walking test were significantly higher in ACB group compared to FNB group. Also incidence of postoperative nausea, vomiting and Sedation was assessed and it was found no statistically significant differences in nausea, vomiting and Sedation between the two groups. Conclusion Saphenous nerve block (adductor canal block) is equivalent to femoral nerve block in achieving postoperative pain but it's superior to femoral nerve block in preserving quadriceps muscle power. So it's competent to be chosen as postoperative analgesic modality after Total knee replacement surgeries.

Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic?

BackgroundArthroplasty services worldwide have been significantly disrupted by the pandemic of coronavirus disease 2019 (COVID-19). This retrospective comparative study aimed to characterize its impact on arthroplasty services in Hong Kong.MethodsFrom January 1 to June 30, 2020, the patients of “COVID-19 cohort” underwent elective total hip or knee replacement in Hong Kong public hospitals. The cohort was compared to the “control cohort” during the same period in 2019. Data analysis was performed to compare the two cohorts’ numbers of operations, hospital admission, orthopaedic clinic attendances, and waiting time.ResultsA total of 33,111 patient episodes were analyzed. During the study period, the elective arthroplasty operations and hospitalizations decreased by 53 and 54%, respectively (P < 0.05). Reductions were most drastic from February to April, with surgical volume declining by 86% (P < 0.05). The primary arthroplasty operations decreased by 91% (P < 0.05), while the revision operations remained similar. Nevertheless, 14 public hospitals continued performing elective arthroplasty for patients with semi-urgent indications, including infection, progressive bone loss, prosthesis loosening, dislocation or mechanical failure of arthroplasty, and tumor. At the institution with the highest arthroplasty surgical volume, infection (28%) was the primary reason for surgery, followed by prosthesis loosening (22%) and progressive bone loss (17%). The orthopaedic clinic attendances also decreased by 20% (P < 0.05). Increases were observed in waiting time and the total number of patients on the waiting list for elective arthroplasty.ConclusionsDespite the challenges, public hospitals in Hong Kong managed to continue providing elective arthroplasty services for high-priority patients. Arthroplasty prioritization, infection control measures, and post-pandemic service planning can enhance hospital preparedness to mitigate the impact of current and future pandemics.

Incidence and Associated Risk Factors for Falls in Older Adults After Elective Total Knee Replacement Surgery: A Prospective Cohort Study.

The aim of the study was to determine the incidence and associated risk factors for falls in older adults in the 12 mos after elective, primary total knee replacement surgery. A prospective observational cohort of older adults undergoing total knee replacement were followed. Baseline measurements included risk factors of history of falls, using a gait aid and number of medications. Falls data were recorded after discharge for 12 mos alongside patient reported outcomes (Oxford Knee Score). Analyses used logistic and negative binomial regression modeling. There were 267 participants (mean age = 70 [6.7] yrs) enrolled. Participants who fell (n = 102 [40.6%]) reported 200 falls in the 12 mos after surgery. The incidence of falls was 2.4 falls per 1000 patient days in the 12 mos after surgery, with the highest incidence (2.6 falls per 1000 patient days) in month 1. Risk factors for falling were a history of falls (adjusted odds ratio = 2.41, 95% confidence interval = 1.35-4.31) and number of central nervous system acting medications taken before surgery (adjusted odds ratio = 1.66, 95% confidence interval = 1.25-2.21). Using a walking aid at baseline was associated with falls after discharge (adjusted incident rate ratio = 2.38, 95% confidence interval = 1.57-3.60). Older adults experience a high incidence of falls after elective total knee replacement. Further research that investigates falls prevention after total knee replacement is required.

Effectiveness of apixaban versus enoxaparin in preventing wound complications and deep venous thrombosis following total knee replacement surgery: A retrospective study.

Enoxaparin, a thromboprophylactic drug that is widely used for preventing deep venous thrombosis (DVT) and surgical wound complications after total knee replacement surgery, can only be administered subcutaneously. Apixaban, a novel factor Xa inhibitor that could be comparable to enoxaparin, is an oral formulation and thus would be easier to manage. To compare the thromboprophylactic effectiveness of apixaban and enoxaparin in patients receiving total knee replacements. In this retrospective, single-institution study, the records of 200 patients who underwent elective total knee replacement surgery were reviewed. Of those, 120 patients had received enoxaparin 4000IU daily (initiated 6hours before surgery), whereas 80 had received apixaban 2.5mg twice daily (initiated 12hours after surgery), for 21days. All patients were examined for major and minor surgical wound complications and DVT incidence during their hospital stay and 7-21days after surgery. No statistically significant differences (P≥.005) were found between the apixaban and enoxaparin groups with regard to minor and major surgical wound complications and DVT incidence. Patients in both groups were comparable in terms of age, hospital stay, and required blood transfusion units. Two enoxaparin-treated patients and one apixaban-treated patient developed DVT (1.5%) during the study period. Oral apixaban is an effective alternative to enoxaparin as a thromboprophylactic drug for patients undergoing elective total knee replacement surgery.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement

The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Implementation of the CJR model in 2016. Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Effectiveness of pre-operative anaemia screening and increased Tranexamic acid dose policies on outcomes following unilateral primary, elective total hip or knee replacement: a statistical analysis plan for an interrupted time series and regression discontinuity study.

Perioperative blood transfusion is associated with poorer postoperative outcomes following hip and knee replacement surgery. Evidence for the effectiveness of some measures aimed at reducing blood transfusions in this setting are limited and often rely on weak pre-post study designs. Quasi-experimental study designs such as interrupted time series (ITS) and regression discontinuity design (RDD) address many of the weaknesses of the pre-post study design. In addition, a priori publication of statistical analysis plans for such studies increases their transparency and likely validity, as readers are able to distinguish between pre-planned and exploratory analyses. As such, this article, written prospective of any analysis, provides the statistical analysis plan for an ITS and RDD study based on a data set of 20,772 primary elective hip and knee replacement patients in a single English NHS Trust. The primary aim is to evaluate the impact of a preoperative anaemia optimisation service on perioperative blood transfusion (within 7 days of surgery) using both ITS and RDD methods. A secondary aim is to evaluate the impact of a policy of increased tranexamic acid dose given at the time of surgery, using ITS methods.

Effectiveness of pre-operative anaemia screening and increased Tranexamic acid dose policies on outcomes following unilateral primary, elective total hip or knee replacement: a statistical analysis plan for an interrupted time series and regression discontinuity study

Perioperative blood transfusion is associated with poorer postoperative outcomes following hip and knee replacement surgery. Evidence for the effectiveness of some measures aimed at reducing blood transfusions in this setting are limited and often rely on weak pre-post study designs. Quasi-experimental study designs such as interrupted time series (ITS) and regression discontinuity design (RDD) address many of the weaknesses of the pre-post study design. In addition, a priori publication of statistical analysis plans for such studies increases their transparency and likely validity, as readers are able to distinguish between pre-planned and exploratory analyses. As such, this article, written prospective of any analysis, provides the statistical analysis plan for an ITS and RDD study based on a data set of 20,772 primary elective hip and knee replacement patients in a single English NHS Trust. The primary aim is to evaluate the impact of a preoperative anaemia optimisation service on perioperative blood transfusion (within 7 days of surgery) using both ITS and RDD methods. A secondary aim is to evaluate the impact of a policy of increased tranexamic acid dose given at the time of surgery, using ITS methods.