Received Joint Replacement Research Articles

Association between mandatory bundled payments and changes in socioeconomic disparities for joint replacement outcomes.

To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid. We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017. We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program. The primary outcome was LEJR complications. Secondary outcomes included 90-day readmissions and mortality. We identified hospitals in the US market areas eligible for CJR. We included beneficiaries in the intervention group who received joint replacement at hospitals in markets randomized to participate in CJR. The comparison group included patients who received joint replacement at hospitals in markets who were eligible for CJR but randomized to control. The study included 1,603,555 Medicare beneficiaries (mean age, 74.6 years, 64.3% women, 11.0% dual-eligible). Among participant hospitals, complications decreased between baseline and intervention periods from 11.0% to 10.1% for dual-eligible and 7.0% to 6.4% for non-dual-eligible beneficiaries. Among nonparticipant hospitals, complications decreased from 10.3% to 9.8% for dual-eligible and 6.7% to 6.0% for non-dual-eligible beneficiaries. In adjusted analysis, CJR participation was associated with a reduced difference in complications between dual-eligible and non-dual-eligible beneficiaries (-0.9 percentage points, 95% CI -1.6 to -0.1). The reduction in disparities was observed among hospitals without prior experience in a voluntary LEJR bundled payment model. There were no differential changes in 90-day readmissions or mortality. Mandatory participation in a bundled payment program was associated with reduced disparities in joint replacement complications for Medicare beneficiaries with low income. To our knowledge, this is the first evidence of reduced socioeconomic disparities in outcomes under value-based payments.

Treatment of femoral neck fractures with closed reduction assisted by joystick technique and cannulated screw fixation

To investigate the effectiveness of joystick technique assisted closed reduction and cannulated screw fixation in the treatment of femoral neck fracture. Seventy-four patients with fresh femoral neck fractures who met the selection criteria between April 2017 and December 2018 were selected and divided into observation group (36 cases with closed reduction assisted by joystick technique) and control group (38 cases with closed manual reduction). There was no significant difference in gender, age, fracture side, cause of injury, Garden classification, Pauwels classification, time from injury to operation, and complications (except for hypertension) between the two groups ( P>0.05). The operation time, intraoperative infusion volume, complications, and femoral neck shortening were recorded and compared between the two groups. Garden reduction index was used to evaluate the effect of fracture reduction, and score of fracture reduction (SFR) was designed and was used to evaluate the subtle reduction effect of joystick technique. The operation was successfully completed in both groups. There was no significant difference in operation time and intraoperative infusion volume between the two groups ( P>0.05). All patients were followed up 17-38 months, with an average of 27.7 months. Two patients in the observation group received joint replacement due to failure of internal fixation during the follow-up, and the other patients had fracture healing. Within 1 week after operation, the Garden reduxtion index of the observation group was better than the control group; the SFR score of the observation group was also higher than that of the control group; the proportion of femoral neck shortening within 1 week after operation and at 1 year after operation in the observation group were lower than those in the control group. The differences of the above indexes between the two groups were significant ( P<0.05). The joystick technique can improve the effectiveness of closed reduction of femoral neck fractures and reduce the incidence of femoral neck shortening. The designed SFR score can directly and objectively evaluate the reduction effect of femoral neck fracture.

High TRB3 expression induces chondrocyte autophagy and senescence in osteoarthritis cartilage

Objective: Osteoarthritis is closely related to aging. Tribbles homologue 3 (TRB3) is found to display age-related expression and contributes to the regulation of cell proliferation, differentiation and fibrosis. In this study, we aimed to investigate the potential involvement of TRB3 in cartilage autophagy and aging in osteoarthritis.Methods: Cartilage tissue samples were collected from osteoarthritis patients who received joint replacement and cadaveric donors. In osteoarthritis cartilage tissue, we analyzed autophagy- and senescence-associated proteins using immunohistochemistry and western blot (WB), in vitro, to confirm the role played by TRB3 in the process of autophagy, cell senescence, and inflammation, small interfering RNA (siRNA) was used for TRB3 knockdown in cells.Results: We found increased level of p62, decreased level of microtubule-associated protein 1A/1B-light chain 3 (LC3) and beclin-1 in cartilage, and increased level of p16 and p21 in tissue samples collected from osteoarthritis patients, indicating decreased autophagy and increased cell senescence. TRB3 knockdown significantly rescued, in vitro, the reduced autophagy and elevated cell senescence in human chondrocyte.Conclusions: Interfering with TRB3 expression in cartilage may serve as a target in the prevention and treatment of age-related osteoarthritis.

Association of Medicare bundled payment model with joint replacement care for people with dementia.

We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery. Retrospective cohort study using 2013-2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge. Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean [SD] age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] -$1577, -$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI -3.17, -0.07, p=0.04), but no changes in 90-day readmission (95% CI -2.68, 0.00, p=0.051). Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.

Primary culture of chondrocytes after collagenase IA or II treatment of articular cartilage from elderly patients undergoing arthroplasty.

Joint replacement surgery provides articular cartilage samples for chondrocyte isolation. To our knowledge, the effect of the collagenase type on releasing of chondrocytes from the extracellular matrix of cartilage is not reported. To determine whether cartilage digested with collagenase IA yielded more chondrocytes than that digested with collagenase II and determine whether chondrocytes isolated with collagenase IA could be cultured in vitro. Cartilage slices collected from 18 elderly patients who received joint replacement surgery (16 hips, 2 knees) were digested sequentially with 0.4% pronase E and 0.02% collagenase IA, or with 0.15% collagenase II alone, or sequentially with 0.4% pronase E and 0.02% collagenase II. We compared cell yield from each method. Cell viability by the most effective method was calculated and plotted. The morphology of cultured monolayer chondrocytes was recorded with a light microscope. Sequential digestion with pronase E and collagenase IA yielded 2566 ± 873 chondrocytes per mg wet cartilage, which was more effective than the other isolation methods (P = 0.018). The average chondrocyte viability could reach 84% ± 8% (n = 11). Light microscopic images showed typical chondrocyte morphology in monolayer cultures. Sequential digestion of human articular cartilage with pronase E and collagenase IA was more effective than collagenase II alone or collagenase II combined with pronase E for releasing chondrocytes from extracellular matrix of cartilage. Chondrocytes isolated with this method could be maintained in monolayer cultures for at least 2 passages with unaltered morphology.

Association of Medicare Mandatory Bundled Payment System for Hip and Knee Joint Replacement With Racial/Ethnic Difference in Joint Replacement Care

There are marked racial/ethnic differences in hip and knee joint replacement care as well as concerns that value-based payments may exacerbate existing racial/ethnic disparities in care. To examine changes in joint replacement care associated with Medicare's Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients. Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic patients undergoing joint replacement in 67 treatment (selected for CJR participation) and 103 control metropolitan statistical areas. The CJR model holds hospitals accountable for spending and quality of joint replacement care during care episodes (index hospitalization through 90 days after discharge). The primary outcomes were spending, discharge to institutional postacute care, and readmission during care episodes. Among 688 346 patients, 442 163 (64.2%) were women, and 87 286 (12.7%) were 85 years or older. Under CJR, spending decreased by $439 for White patients (95% CI, -$718 to -$161; from pre-CJR spending in treatment metropolitan statistical areas of $25 264) but did not change for Black patients and Hispanic patients. Discharges to institutional postacute care decreased for all groups (-2.5 percentage points; 95% CI, -4.7 to -0.4, from pre-CJR risk of 46.2% for White patients; -6.0 percentage points; 95% CI, -9.8 to -2.2, from pre-CJR risk of 59.5% for Black patients; and -4.3 percentage points; 95% CI, -7.6 to -1.0, from pre-CJR risk of 54.3% for Hispanic patients). Readmission risk decreased for Black patients by 3.1 percentage points (95% CI, -5.9 to -0.4, from pre-CJR risk of 21.8%) and did not change for White patients and Hispanic patients. Under CJR, Black-White differences in discharges to institutional postacute care decreased by 3.4 percentage points (95% CI, -6.4 to -0.5, from the pre-CJR Black-White difference of 13.3 percentage points). No evidence was found demonstrating that Black-White differences changed for other outcomes or that Hispanic-White differences changed for any outcomes under CJR. In this cohort study of patients receiving joint replacements, CJR was associated with decreased readmissions for Black patients. Furthermore, Black patients experienced a greater decrease in discharges to institutional postacute care relative to White patients, representing relative improvements despite concerns that value-based payment models may exacerbate existing disparities. Nonetheless, differences between White and Black patients in joint replacement care still persisted even after these changes.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations

BackgroundOverlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. MethodsWe conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). ResultsWe studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net. ConclusionCJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Risk factors for periprosthetic joint infection after primary artificial hip and knee joint replacements.

We aimed to explore the risk factors for periprosthetic joint infection (PJI) after primary artificial hip and knee joint replacements by performing a case-control study. The clinical data of patients receiving primary hip and knee joint replacements were retrospectively analyzed. The case group included 96 patients who suffered from PJI, comprising 42 cases of hip joint replacement and 54 cases of knee joint replacement. Another 192 patients who received joint replacement at the ratio of 1:2 in the same period and did not suffer from PJI were selected as the control group. Differences between the two groups were compared in regard to etiology, pathogen, blood type, urine culture, body mass index (BMI), surgical time, intraoperative blood loss, postoperative 1st day and total drainage volumes, length of hospitalization stay, and history of surgery at the affected sites. Gram-positive bacteria were the main pathogens for PJI. The most common infection after hip joint replacement was caused by Staphylococcus epidermidis, which accounted for 38.10%, while Staphylococcus aureus was mainly responsible for the infection of knee joint (40.74%). High BMI, long surgical time, large postoperative drainage volume, long hospitalization stay, history of surgery at incisions, previous use of immunosuppressants, preoperative hypoproteinemia and superficial infection were independent risk factors (p < 0.05). PJI after primary replacement was mainly caused by gram-positive bacteria, and patients with high BMI, long surgical time, large postoperative drainage volume, long hospitalization stay, history of surgery at incisions, previous use of immunosuppressants, preoperative hypoproteinemia and superficial infection were more vulnerable.

Effects of immersive virtual reality therapy on intravenous patient-controlled sedation during orthopaedic surgery under regional anesthesia: A randomized controlled trial.

BackgroundImmersive virtual reality (IVR) is a form of distraction therapy that has shown potential as an analgesia and sedation sparing agent. This study assessed the effect of IVR on the self-administered sedation requirements of patients undergoing joint replacement surgery under regional anesthesia in a single center.Methods and findingsThis study was a single-center, randomized control trial at St Vincent’s Hospital in Melbourne, Australia. Fifty patients undergoing elective total knee and total hip arthroplasty were randomized to IVR and Propofol patient-controlled sedation (PCS) or propofol PCS alone. The primary outcome measure was intra-operative propofol use. Secondary outcomes included pattern of propofol use over time, use of adjunct analgesia, unmet propofol demand, and patient satisfaction survey scores. Of 50 total patients, 25 received IVR in conjunction with PCS, and 25 received PCS alone. All patients received adjunct analgesia from the treating Anesthesiologist. Median propofol use/hour over the entire procedure in the control group was 40 (11.1, 93.9) mg/hour compared with 45 (0, 94.7) mg/hour in the IVR group (p = 0.90). There were no differences in patterns of propofol use over the course of each procedure. Adjusting for various baseline characteristics did not change the results. Postoperative satisfaction scores were equivalent in both groups. The VR intervention was well tolerated by all patients, with no report of major side effects. Key limitations were relatively small sample size, the non-blinded nature of the study, and use of adjunct analgesia.ConclusionsIn patients receiving joint replacement surgery under regional anesthesia with PCS, IVR was well tolerated but did not decrease the overall sedation requirement.

Pulmonary hypertension could be a risk for deep vein thrombosis in lower extremities after joint replacement surgery.

A background of Pulmonary Hypertension (PH) indicates a progressive elevation of pulmonary vascular resistance, leading to overfilling, elevation of venous pressure, congestion in various organs, and edema in the venous system. This study aimed to investigate whether PH is a risk factor for deep vein thrombosis (DVT) of the lower extremities after hip and knee replacement surgery. A total of 238 patients who received joint replacement of lower extremities in our department of orthopedics from January 2009 to January 2012 were examined by echocardiography and Color Doppler flow imaging (CDFI) of the lower extremities. Based on pulmonary artery pressure (PAP), the patients were divided into a normal PAP group (n=214) and PH group (n=24). All the patients were re-examined by CDFI during post-operative care. Among the 238 patients, 18 had DVT in the lower extremities after the operation. DVT total incidence rate was 7.56% (18/238). In the PH group, 11 patients had DVT (45.83%, 11/24), but in the normal PAP group, only 7 had DVT (3.27%, 7/214). The incidence of DVT was significantly lower in the normal PAP group than in the PH group (P<0.01). In addition, there was a positive correlation between PAP and the incidence of DVT. PH could be a high-risk factor for the occurrence of DVT in patient's lower extremities after joint replacement surgeries.

Orthopaedic registries: the Australian experience.

The Australian Orthopaedic Association National Joint Replacement Registry first began data collection on 1 September 1999 and full nationwide implementation commenced in January 2003.The purpose of the Registry is to improve the quality of care for individuals receiving joint replacement surgery.The Registry enables surgeons, academic institutions, governments and industry to request specific data that are not available in published annual reports.There is an established system for identifying prostheses with a higher than anticipated rate of revision (HTARR) which was introduced in 2004.The higher rate of revision for the ASR Hip Resurfacing System was first identified by this process in 2007.There has been a reduction in revision hip and knee replacement over the years that the Registry has been in operation, and the addition of Patient Reported Outcome Measures (PROMs) and data linkage will enable more extensive analysis of joint replacement surgery in the future.Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180071

An interdisciplinary approach to improve surgical antimicrobial prophylaxis

PurposeThe purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework.Design/methodology/approachOrthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages.FindingsSAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders.Practical implicationsDue to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively.Originality/valueRather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.

Combination COX-2 inhibitor and metformin attenuate rate of joint replacement in osteoarthritis with diabetes: A nationwide, retrospective, matched-cohort study in Taiwan.

BackgroundOsteoarthritis (OA) is the most common form of arthritis associated with an increased prevalence of type 2 diabetes mellitus (T2DM), however their impact on decreasing joint replacement surgery has yet to be elucidated. This study aimed to investigate if the combination of COX-2 inhibitor and metformin therapy in OA with T2DM were associated with lower the rate of joint replacement surgery than COX-2 inhibitor alone.MethodsIn total, 968 subjects with OA and T2DM under COX-2 inhibitor and metformin therapy (case group) between 1 January to 31 December 2000 were selected from the National Health Insurance Research Database of Taiwan, along with 1936 patients were the 1:2 gender-, age-, and index year-controls matched without metformin therapy (control group) in this study. Cox proportional hazards analysis was used to compare the rate of receiving joint replacement surgery during 10 years of follow-up.ResultsAt the end of follow-up, 438 of all enrolled subjects (15.08%) had received the joint replacement surgery, including 124 in the case group (12.81%) and 314 in the control group (16.22%). The case group tended to be associated with lower rate of receiving the joint replacement surgery at the end of follow-up than the control group (p = 0.003). Cox proportional hazards regression (HR) analysis revealed that study subjects under combination therapy with metformin had lower rate of joint replacement surgery (adjusted HR 0.742 (95% CI = 0.601–0.915, p = 0.005)). In the subgroups, study subjects in the combination metformin therapy who were female, good adherence (>80%), lived in the highest urbanization levels of residence, treatment in the hospital center and lower monthly insurance premiums were associated with a lower risk of joint replacement surgery than those without.ConclusionsPatients who have OA and T2DM receiving combination COX-2 inhibitors and metformin therapy associated with lower joint replacement surgery rates than those without and this may be attributable to combination therapy much more decrease pro-inflammatory factors associated than those without metformin therapy.

The Sequelae of Metallosis Resulting in Skin Pigmentation and Tattooing: A Case Presentation and Literature Review.

With advancing technologies in orthopedics and increasing demands of the population for orthopedic interventions, younger patients are now receiving joint replacements. One of the potential risks of joint replacement is metallosis, or the local and systemic release of metal ions. Metallosis is caused by the release of metallic debris, secondary to hardware failure. The phenomenon is most commonly associated with failed metal-on-metal hip prostheses and is characterized locally by heavy staining of surrounding soft tissue, metallic synovitis, joint effusion, and gradual loosening of the prosthesis. Additionally, metallic debris can also lead to periarticular superficial skin manifestations. The release of metal ions has further been known to lead to systemic upsets including neurologic deficit (declining vision, hearing, or cognition; headaches), cardiac failure, and hypothyroidism. As the number of patients seeking major orthopedic interventions grows, the incidence of metallosis-related skin tattooing will also increase. The structural components of a failed joint replacement can be revised (improving patients' pain and functioning). However, any skin tattooing secondary to metallosis presents the treating dermatologist with clinical challenge, due to lack of research regarding treatment of this condition. Our aim is to review the published literature on metallosis, including the pathophysiology. After assessing publications on the treatment of traumatic and cosmetic tattooing, we hope to stimulate further research regarding treatment. This article should also serve to remind orthopedic surgeons that with increasing patient concern regarding cosmesis, a multispecialty approach including referral to a dermatologist is valuable.

Comparison of analgesic effects of epidural Morphine versus lumbosacral plexus block in elderly patients undergoing hip joint replacement

Objective To compare the analgesic effects of epidural Morphine versus lumbosacral plexus block in patients undergoing hip joint replacement. Methods A total of 94 ASA Ⅰ~Ⅱ patients undergoing hip surgery with combined spinal epidural anesthesia(CSEA) were selected and randomized into 4 groups: Group M received a single epidural injection of 2 mg Morphine for analgesia, Group MN1 received an epidural injection of 1 mg Morphine combined with lumbosacral plexus block, Group MN2 received an epidural injection of 2 mg morphine combined with lumbosacral plexus block, and Group N received lumbosacral plexus block. All patients were administered intramuscular parecoxib for 3 days after surgery and, if the visual analogue scale(VAS)≥4, additional intramuscular tramadol. Patient-controlled intravenous analgesia(PCIA) was applied if pain relief was insufficient after Tramadol treatment. Postoperative analgesic effects, the ability to ambulate and side effects were monitored. Results VAS scores gradually increased in the 4 groups after surgery and were higher between the morning of the 1st day and the evening of the next day than at 4 hours after surgery in all the 4 groups. There were no significant differences in VAS scores between rest and exercise conditions in any of the 4 groups. Ambulatory VAS scores were lower in Groups MN1 and MN2 than in Groups M and N 6 hours after surgery, while resting VAS scores had no significant differences between the 4 groups. Resting and ambulatory VAS scores were both lower in Groups MN1 and MN2 than in Groups M and N 6 hours after surgery, while they had no significant differences between either Groups MN1 and MN2 or Groups M and N 4-8 hours after surgery. Resting and ambulatory VAS scores were lower in Groups M, MN1 and MN2 than in Group M on the morning of the day after surgery, and more patients in Group N needed early tramadol and PCIA for rescue analgesia. Muscle strength was lower in Groups MN1 and MN2 than in Groups M and N 4 hours and on the morning of the day after surgery. No significant differences between the groups were found in standing ability 6 hours after surgery and in motor activity on the morning of the day after surgery. The incidence of urinary retention was higher in Groups M and MN2 than in Groups MN1 and N, and was higher in Group MN1 than in Group N. The incidence of pruritus was higher in Groups M and MN2 than in Group N. There was no significant difference in Ramsay sedation scores and postoperative nausea and vomiting(PONV) between the groups. Conclusions Epidural morphine combined with lumbosacral plexus nerve block can provide better analgesic effects than a single dose of epidural morphine or lumbosacral plexus nerve block in elderly patients undergoing hip joint replacement. Although the synergy of the combination has certain influence on early muscle strength recovery, it does not affect early postoperative rehabilitation training. With the combined use of parecoxib and lumbosacral plexus nerve block, epidural injection of 1 mg and 2 mg morphine provides similar analgesic effects, but epidural injection of 2 mg morphine results in a higher incidence of urinary retention. Thus, a small dose of epidural morphine combined with lumbosacral plexus nerve block is recommended for postoperative analgesia in elderly patients receiving hip joint replacement. Key words: Analgesia, epidural; Arthroplasty, replacement, hip; Morphine; Lumbosacral

Demographic and clinical characteristics of patients having received joint replacement versus high tibial osteotomy surgery: A comparison of two cohorts

Purpose: Total knee arthroplasty (TKA) replaces the osteoarthritic knee, while High Tibial Osteotomy (HTO) attempts to preserve it. TKA has been traditionally viewed as a treatment option for older patients with end-stage disease, and HTO a treatment option for younger patients with mal-alignment and OA confined to one tibiofemoral compartment. With increasing rates of TKA, and decreasing rates of HTO, it is important to better understand the eligibility criteria for these quite disparate surgeries. Therefore, the purpose of the present study was to investigate the demographic and clinical characteristics of patients with knee OA who received TKA compared to patients who received HTO. Methods: Patients with or at high risk for developing knee OA were selected from the Osteoarthritis Initiative (OAI), a multi-center, publically accessible database. Only those patients with varus alignment that received TKA or partial medial uniarthroplasty since enrollment were included. Patients who received medial opening wedge HTO were included from a separate cohort from a single centre specializing in knee realignment or osteotomy surgery. Baseline demographic and clinical characteristics (age, body mass index [BMI], sex, Knee Injury and Osteoarthritis Outcomes Score [KOOS]) were collected for both groups. Radiographic measures included lower limb frontal plane alignment (mechanical axis angle [MAA]), Kellgren and Lawrence grade of disease severity (KLG), and medial/lateral joint space width (MJSW/LJSW). Patients from the two cohorts were then split into subgroups according to age (<50y, 50-59y, 60-69y, ≥70y). In patients that received bilateral HTO or TKA surgery, only the first surgical limb was included. Independent t-tests and chi-squared analyses were used to compare differences in means and proportions between groups, respectively. A bonferroni correction for multiple comparisons was applied and adjusted the significance level to p<0.002. Results: Data from 834 patients having received HTO (n=565) or TKA (n=269) were included. Overall, patients receiving HTO were younger with more varus alignment (p<0.001). A total of 367 HTO (n=216) and TKA (n=151) patients were between the ages of 50 and 69. In those patients, although lower limb alignment was more varus in patients receiving HTO (-7.9°±3.7°) vs. TKA (-4.4°±3.9°), radiographic disease severity (KLG) was not significantly different between groups. Although JSW could not be directly compared between cohorts, 90-96% of patients that received joint replacement had minimal to no lateral joint space narrowing (grade 0-1), suggesting lateral compartment disease did not make them ineligible for HTO. BMI (HTO: 29.2±4.4 kg/m2; TKA: 31.0±4.7 kg/m2) and proportions of degenerative vs. post-traumatic OA (HTO: 92%vs.8%; TKA: 93%vs.7%) were also similar between groups (p<0.001). Significantly more males received HTO (82%, p<0.001); significantly more females received TKA (60%, p<0.001). Preoperative KOOS 4 subdomains were consistently lower (worse) in patients that received HTO compared to patients that received TKA, with significant differences for pain (p<0.001) and quality of life (p<0.001). Conclusions: These findings suggest substantial overlap in demographic and clinical characteristics between patients receiving TKA vs. HTO, particularly in those between 50 and 69 years of age. Sex is a notable exception, with relatively few females receiving HTO. TKA was not associated with greater radiographic or patient-reported disease severity. Identifying optimal eligibility criteria for both surgical interventions requires re-evaluation.

CORR Insights®: Is There a Difference in TKA Risk of Revision in Highly Crosslinked versus Conventional Polyethylene?

Where Are We Now? Previously published large, population-based studies [1, 6] examining the differences between highly crosslinked polyethylene versus conventional polyethylene have yielded inconsistent results in TKA. Inacio et al. [6] did not find a difference in cobalt-chromium highly crosslinked polyethylene versus conventional polyethylene for TKA bearings in a large US sample. However, a 2013 report from the Australian registry [1] found that highly crosslinked polyethylene tibial inserts in TKAs lowered the risk of revision versus conventional polyethylene. The current study by Paxton and colleagues is important because researchers used a large, US registry [8] to examine the effect of highly crosslinked polyethylene versus conventional polyethylene on revision risk in TKA. Paxton and colleagues did not find differences in revision risk for highly crosslinked polyethylene compared to conventional polyethylene at 5 years, but the authors did find that highly crosslinked polyethylene added cost to the surgical procedure. These results bring into question the value of this change in clinical practice for this specific patient population employing these specific implants. This work supports previously published data from a community registry and basic science publications [3-5]. Where Do We Need To Go? In some respects, the findings by Paxton and colleagues differ from those of the Australian Joint Replacement Registry which utilized multiple manufacturers and processes [1]. The Australian registry indicated better specific manufacturers’ results in terms of revision 5 years postoperatively. Paxton and colleagues did not address the issue for all implants, but they did individually evaluate two of the most popular implants utilized by these surgeons and demonstrated no differences in revision rates. How Do We Get There? Future studies will need to evaluate all implants not only with respect to revision rates, but also including patient-reported outcomes, pain, function, return to work, and duration of followup. The best way to improve our outcomes will be to require the use of registry databases throughout the world. We must scrutinize the differences that are inevitably found. An international effort called the International Society of Arthroplasty Registers [7] is currently underway to establish similar databases and end points. Their stated purpose is to improve outcomes for individuals receiving joint replacement surgery worldwide. The focus of the society is to further enhance the capacity of individual registries to meet their own aims and objectives. The society is involved in the development of frameworks to encourage collaborative activities and provides a support network for established and developing registries. The addition of the American Joint Replacement Registry and the California Joint Replacement Registry [2] are vital to this effort.

AB0187 Can joint surgeries improve control of disease activity in patients with long-standing rheumatoid arthritis?: introducing the notion of “surgical window of opportunity”

BackgroundTreatments based on measuring disease activity and adjusting therapy accordingly optimizes outcomes in rheumatoid arthritis (RA). In patients with long-standing disease, joint surgeries may be preferred due to considerable joint...

Age at hip or knee joint replacement surgery predicts likelihood of revision surgery

We compared revision and mortality rates of 4668 patients undergoing primary total hip and knee replacement between 1989 and 2007 at a University Hospital in New Zealand. The mean age at the time of surgery was 69 years (16 to 100). A total of 1175 patients (25%) had died at follow-up at a mean of ten years post-operatively. The mean age of those who died within ten years of surgery was 74.4 years (29 to 97) at time of surgery. No change in comorbidity score or age of the patients receiving joint replacement was noted during the study period. No association of revision or death could be proven with higher comorbidity scoring, grade of surgeon, or patient gender. We found that patients younger than 50 years at the time of surgery have a greater chance of requiring a revision than of dying, those around 58 years of age have a 50:50 chance of needing a revision, and in those older than 62 years the prosthesis will normally outlast the patient. Patients over 77 years old have a greater than 90% chance of dying than requiring a revision whereas those around 47 years are on average twice as likely to require a revision than die. This information can be used to rationalise the need for long-term surveillance and during the informed consent process.

An evaluation of the effectiveness of relaxation therapy for patients receiving joint replacement surgery

To examine the effect of relaxation therapy on reducing patient anxiety and pain before and after total joint replacement. Despite the use of analgesics, patients may feel anxiety and pain before and after surgery, delaying their recovery. An experimental control group pretest-post-test quasi-experimental design was employed. Subjects (n = 93) recruited from a medical centre in Taipei, Taiwan, from November 2006-March 2007 were randomly assigned to experimental (n = 45) and control (n = 48) groups. Subjects in the experimental group received relaxation therapy from the day before surgery to the third postoperative day. Researchers helped participants listen to a breath relaxation and guided imagery tape for 20 minutes daily. A pain and anxiety scale questionnaire, the State-Trait Anxiety Inventory questionnaire, blood pressure and heart rate were monitored before and after intervention. The average age of the 93 patients was 71·0 (SD 11·1) years. The least pain severity scores in the experimental were lower than those in the control group (p < 0·05) but both experienced the same level of worst or average pain (p > 0·05). The mean difference in the pain score before and after intervention in the experimental group on the pre-op day (t = 2·675, p = 0·009) and post-op day one (t = 3·059, p = 0·003) was greater than that in the control group (0·48 SD 0·94 vs. 0·10 SD 0·30 and 0·93 SD 1·46 vs. 0·20 SD 0·71, respectively). The two groups differed significantly in systolic blood pressure (F = 6·750, p < 0·05) but not in mean blood pressure, heart rate, or State-Trait Anxiety Inventory scores (p > 0·05). Patients reported that relaxation therapy helped them relax and promoted sleep. Relaxation therapy could complement analgesics to help postoperative patients better manage pain and anxiety. Clinical practice should include complementary relaxation therapy to alleviate pain and anxiety in patients with joint replacement.