Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis

A Proposed Patient Selection Algorithm for Total Joint Arthroplasty Same-Day Discharge From an Ambulatory Surgery Center

BACKGROUND

Identifying appropriate patients for same-day discharge (SDD) total joint arthroplasty (TJA) is critical for maintaining optimal patient safety and outcomes. This study investigated patient outcomes after SDD TJA at a single ambulatory surgery center (ASC) and proposes a TJA patient-selection algorithm based on findings and existing literature.

METHODS

A retrospective chart review of 660 patients was performed between July 2019 and October 2021 for all patients who underwent primary TJA in a single ASC. Successful SDD, length of surgery, estimated blood loss (EBL), complications, and readmission events were recorded for each patient. There were 20 total complications in 331 primary total knee arthroplasties (TKAs) (6.0%) and 15 total complications in 329 primary total hip arthroplasties (THAs) (4.6%).

RESULTS

There was one direct admission to the hospital in TKA patients and four direct admissions in THA patients, making the successful SDD rate 99.7% in TKAs, 98.8% in THAs, and 99.2% overall. In the TKA cohort, body mass index was associated with total complications (r = -0.15, P = 0.006); comorbidities with wound complications (P = 0.006); and EBL was with readmissions (r = 0.30, P < 0.001), revision surgery (r = 0.12, P = 0.04), and total complications (r = 0.16, P = 0.03). In the THA cohort, body mass index was weakly associated with wound complications (r = -0.12, P = 0.02), EBL was with emergency department visits (r = 0.18, P = 0.002) and total complications (r = 0.14, P = 0.01). However, there was no direct association between any of the analyzed characteristics and direct admission.

CONCLUSIONS

In our ASC cohort, patients had low rates of perioperative complications and hospital admissions, supporting the safety of SDD TJA using our proposed evidence-based algorithm to guide patient selection for SDD.

Safety of Same-Day Total Joint Replacement: A Population-Based Cohort Study

PURPOSE

Total joint arthroplasty (TJA) has seen a rapid increase in same-day surgery (SDS), particularly since the COVID-19 pandemic. One limitation of prior research on this topic is that data derived from single (usually high volume) centers whose experience may not be generalizable. The purpose of this study was to analyze the success rates of same-day TJA using population level data in Canada's most populous province.

METHODS

Data from Ontario's linked, administrative, healthcare databases were obtained for all patients undergoing planned outpatient elective total hip or knee arthroplasty (total hip arthroplasty [THA] or total knee arthroplasty [TKA]) between April 1 2016 and March 31, 2022. Rates of successful same-day TJA were calculated (ie, proportion of planned outpatients actually discharged same day). Predictors of successful same-day discharge were compared between the groups.

RESULTS

Overall,2,776 TKA and 3,380 THA patients planned for same-day discharge over the study period. This increased from 0.6% in 2016 to 23.8% in 2021 of patients selected for same-day surgery, 11.3% (TKA) and 11.6% (THA) failed same-day discharge. After matching on age, joint, Charlson score, type of institution, and year of surgery, female patients were markedly more likely to fail SDS TJA compared with male patients (hazard ratio: 1.14, 95% confidence interval, 1.05 to 1.25). Other predictors of unsuccessful same-day discharge included frailty, presence of comorbidities (for TKA), and Class III or higher obesity (for THA).

CONCLUSION

Rates of same-day surgery are rising rapidly, and nearly 90% of patients planned as same-day cases are successfully discharged as such. Female patients are at markedly higher risk of failed SDS TJA. Other risk factors include presence of comorbidities and frailty. It is important to evaluate SDS TJA programs to ensure that they are safe and accessible for female arthroplasty patients.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Database Study.

Unicompartmental Knee Arthroplasty Offers More Natural Feeling Joints Compared with Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

Unicompartmental knee arthroplasty (UKA) preserves healthy cartilage and may provide a more "natural-feeling" joint compared with total knee arthroplasty (TKA). The Forgotten Joint Score (FJS) is increasingly used to assess joint awareness. We aimed to systematically compare FJS outcomes in patients undergoing UKA versus TKA.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we searched PubMed, Embase, Scopus, and Web of Science. We included studies reporting FJS in UKA vs. TKA, assessed risk of bias using the Newcastle-Ottawa Scale, and Cochrane RoB-2, and conducted random-effects meta-analyses to calculate pooled mean differences (MD), and sensitivity analyses were performed to assess the robustness of the findings.

Results

Ninteen studies (16 cohort, 3 randomized clinical trials; 4,500 knees) were included. Overall, the pooled MD in FJS favored UKA by 8.45 points (95% CI: 6.03-10.88; p < 0.001), indicating lower joint awareness. However, heterogeneity was high (I2 = 96.24%) and publication bias was detected. Sensitivity analyses, including a leave-one-out analysis and an analysis restricted to randomized controlled trials, confirmed the consistency of the results, with no single study disproportionately influencing the findings.

Conclusion

Despite substantial heterogeneity, these findings suggest that UKA may offer superior joint awareness compared with TKA.

Level of Evidence

Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative analysis of hypobaric versus hyperbaric bupivacaine for spinal anesthesia in day-case anorectal surgery: A prospective observational study

BACKGROUND

This study aimed to compare the efficacy, safety, and discharge times of patients undergoing day-case anorectal surgery using 5 mg hyperbaric bupivacaine versus 5 mg hypobaric bupivacaine. The evaluation was based on Fast-Track Scoring criteria, which assess the suitability of patients for day-case surgery.

METHODS

A prospective observational study was conducted at Ankara City Hospital, including 80 patients aged 18 to 65 years within American Society of Anesthesiologists I-II risk groups scheduled for day-case anorectal surgery. All patients received spinal anesthesia with either 5 mg of 0.5% hyperbaric bupivacaine or 5 mg of 0.5% hypobaric bupivacaine. Hemodynamic parameters, sensory and motor block durations, time to first analgesic need, urination time, and discharge time were meticulously recorded and analyzed. Statistical analyses were performed using the independent samples t test and Mann-Whitney U test, with significance set at α = 0.05.

RESULTS

The hypobaric group exhibited significantly shorter sensory and motor block durations, enabling faster surgical readiness and earlier discharge. Both groups maintained comparable hemodynamic stability and postoperative complication rates. Shorter discharge times in the hypobaric group may offer potential benefits for patient turnover and cost-effectiveness.

CONCLUSION

For patients undergoing day-case anorectal surgery, 5 mg hypobaric bupivacaine provides faster recovery and shorter discharge time than hyperbaric bupivacaine, without compromising safety. These findings suggest that hypobaric bupivacaine may be a more suitable choice in day-case settings, contributing to improved resource utilization and patient satisfaction.

Unicompartmental knee arthroplasty: an exemplar of surgical and engineering collaboration

Cite this article: Bone Jt Open  2024;5(12):1120–1122.

Robotic-Assisted Medial Unicompartmental Knee Arthroplasty Provides Better FJS-12 Score and Lower Mid-Term Complication Rates Compared to Conventional Implantation: A Systematic Review and Meta-Analysis

Background: Robotic-assisted unicompartmental arthroplasty (rUKA) is gradually gaining more popularity than its conventional counterpart (cUKA). Current studies are highly heterogenic in terms of methodology and the reported results; therefore, establishing the optimal recommendation for patients becomes less straightforward. For this reason, this meta-analysis aims to provide an up-to-date evidence-based analysis on current evidence regarding clinical outcomes and complication rates following rUKA and cUKA. Methods: A meta-analysis was conducted following PRISMA guidelines. Five databases were searched, PubMed via MEDLINE, Epistemonikos, Cochrane Library, Web of Science, and Scopus. The relevant inclusion criteria were as follows: comparative clinical studies in which medial rUKA was compared to medial cUKA (prospective or retrospective designs), (2) human studies, (3) meta-analyses for cross-referencing, and (4) English language. The relevant extracted data were patient demographics, patient-reported outcome measures (PROMs), range of motion, and complications. A random-effects meta-analysis and subgroup analysis were conducted. The results include mean differences (MDs) and odds ratios (ORs), along with 95% confidence intervals (CIs) for continuous and binary variables, respectively. Results: rUKA showed a higher overall FJS-12 score compared to cUKA, with MD = 6.02 (95%CI: -0.07 to 12.1), p = 0.05. At 6 months postoperatively, the MD increased to 10.31 (95%CI: 5.14 to 15.49), p < 0.01. At a minimum 36-month follow-up, cUKA had a higher all-cause revision rate, with OR = 3.31 (95%CI: 1.25 to 8.8), p = 0.02, and at a minimum 60-month follow-up, a higher aseptic loosening rate, with OR = 3.86 (95%CI: 1.51 to 9.91), p < 0.01, compared to rUKA. Conclusions: rUKA provides better FJS-12 results compared to cUKA, as well as lower all-cause revision and aseptic loosening rates at 36- and 60-month follow-up, respectively. However, long-term follow-up is still pending.

The outpatient experience in unicompartmental knee arthroplasty: How to perform safely in the ambulatory surgery center

The number of outpatient unicompartmental knee arthroplasty (UKA) procedures has increased substantially over the last decade. The ambulatory surgery center (ASC) and hospital outpatient department provide a safe, cost-effective alternative with significant cost savings to the healthcare system. Advancements in technology and perioperative management strategies have expanded the number of eligible patients to optimize outcomes with a focus on safety. Therefore, this review will describe the safety, efficacy, economics, and perioperative protocols for performing UKA in an outpatient setting. Patient selection, risk factors, patient education and expectations, anesthesia, pain management strategies, and outcomes will be discussed.

Is outpatient joint arthroplasty safe in a high volume academic centre? A retrospective monocentric study using an institutional pathway

PURPOSE

Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice.

METHODS

We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied.

RESULTS

498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59 years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters.

CONCLUSION

Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.

Robotic-arm-assisted lateral unicompartmental knee arthroplasty leads to high implant survival and patient satisfaction at mean 10-year follow-up

BACKGROUND

There is a lack of literature reporting on long-term outcomes following robotic-arm-assisted lateral unicompartmental knee arthroplasty (UKA). This study assessed the long-term survivorship, patient-reported satisfaction and pain scores following robotic-arm-assisted lateral UKA for lateral compartment osteoarthritis (OA).

METHODS

A single surgeon's database was reviewed to identify all patients who underwent robotic-arm-assisted lateral UKA with a cemented, fixed-bearing prosthesis prior to May 2015. Patients were contacted to determine implant survivorship, satisfaction and pain. Kaplan-Meier models were applied to analyse survival.

RESULTS

A total of 77 knees (70 patients) with a mean follow-up of 10.2 ± 1.5 years (range: 8.1-13.3) were included. Five knees were revised, corresponding to a 10-year survivorship of 96.1% and estimated survival time of 12.7 ± 0.3 years (95% confidence interval: 12.2-13.2) with all-cause revision as the endpoint. Unexplained pain (40.0%) and progression of OA (40.0%) in contralateral compartments were the most reported reasons for revision. Among patients without revision, 94.4% were either satisfied or very satisfied with their lateral UKA and the average pain score was 1.1.

CONCLUSION

Robotic-arm-assisted lateral UKA led to high implant survivorship and patient satisfaction, and low pain scores at long-term follow-up. Progression of OA in contralateral compartments and unexplained pain were the most frequent reasons for revision. These findings support the continued use of robotic-arm-assisted lateral UKA for lateral compartment OA; however, its clinical value over conventional techniques remains to be established in prospective comparative studies.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Predicting postoperative coronal alignment after fixed-bearing unicompartmental knee arthroplasty using a new morphological assessment method: the arithmetic hip-knee-ankle angle

PURPOSE

Only a few reports have been published so far on factors that predict postoperative coronal alignment after unicompartmental knee arthroplasty (UKA). The purpose of this study is to clarify the relationship between the arithmetic hip-knee-ankle angle (aHKA) and postoperative coronal alignment after medial fixed-bearing UKA.

METHODS

One hundred and one consecutive patients (125 knees) who underwent medial fixed-bearing UKA were assessed. Pre- and postoperative coronal HKA angles, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and the thickness of the tibial and femoral bone cut were measured. aHKA was calculated as 180° - LDFA + MPTA. Correlations between postoperative HKA angle and aHKA, LDFA, and MPTA were investigated by single regression analysis. After the patients were divided into three groups according to the postoperative HKA angle, i.e., HKA angle > 180°, 175° < HKA angle ≤ 180°, and HKA angle ≤ 175°, aHKA, LDFA, MPTA, preoperative HKA angle, and the thickness of the distal femoral as well as tibial bone cut were compared among the three groups.

RESULTS

aHKA and MPTA were positively correlated with postoperative HKA angle, while no correlation was found between postoperative HKA angle and LDFA. Among the three groups classified by postoperative HKA angle, significant differences were found in aHKA, MPTA, and preoperative HKA angle, while no significant difference was found in LDFA and the amount of distal femoral and tibial osteotomies.

CONCLUSIONS

aHKA was correlated with postoperative HKA angle after medial fixed-bearing UKA, which was probably due to the influence of MPTA.

Magnitude of Change in Leg Length and Clinical Impact Following Medial Unicompartmental Knee Arthroplasty

BACKGROUND

Change in leg length and leg-length discrepancy (LLD) are common concerns among patients undergoing medial unicompartmental knee arthroplasty (UKA). This study aimed to quantify the magnitude of leg-length change, prevalence of postoperative LLD, and their clinical implications following medial UKA.

METHODS

Leg length and mechanical hip-knee-ankle angle (mHKA) were retrospectively measured in 332 patients following unilateral robotic-arm assisted medial UKA for medial compartment osteoarthritis, using calibrated long-leg radiographs. The Knee Injury and Osteoarthritis Otcome Score for Joint Replacement and patient satisfaction were analyzed to assess impact of leg-length change and LLD on outcomes.

RESULTS

Following medial UKA, median leg-length change was 2.0 mm (interquartile range, -1.0 to 5.0 mm; P < .001) with a mean correction in mHKA of 4.4° ± 2.7 (P < .001). A total of 158 patients (48%) had a leg-length increase by 0 to 5 mm, 64 (19%) by 6 to 10 mm, and 11 (3%) by >10 mm. Leg-length change was positively correlated with mHKA correction (R = 0.44, P < .001). Postoperatively, moderate (5 to 10 mm) and substantial LLD (≥10 mm) were present in 49% and 17% of patients, respectively. Four-year Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were comparable between patients with and without substantial postoperative LLD (P = .976). Proportions of satisfied patients were similar between groups (P = .687).

CONCLUSION

Following medial UKA, the majority of patients had a moderate increase in leg length, the magnitude of which was positively correlated to the correction in mechanical alignment. Postoperative substantial LLD was not uncommon (17% prevalence); however, it had no significant impact on patient-reported outcomes or satisfaction at 4 years follow-up.

Exploring the relationship between bearing extrusion and postoperative persistent pain in Oxford unicompartmental knee arthroplasty: A trajectory measurement study

Objective: The aim of the study is to explore the relationship between the extrusion of the meniscus bearing and postoperative persistent pain of Oxford unicompartmental knee arthroplasty.

Methods: Patients undertaking Oxford UKA from January 2019 to June 2020 were retrospectively analyzed. Intraoperatively, the displacement and movement trajectory of the meniscus bearing was recorded by the specially designed gridding mold of the tibial component. The k-means clustering analysis was applied based on the incidence of postoperative persistent knee pain and the bearing extrusion distance. The intraoperative meniscus bearing movement trajectories were analyzed between the two groups and the patients’ clinical outcomes and radiographic assessments.

Results: The k-means clustering analysis indicated that the extrusion of the bearing of 5 mm was the grouping standard. There were 27 patients with 30 knees in the extrusion group and 58 patients with 68 knees in the non-extrusion group. The proportion of optimal bearing movement trajectories in the extrusion group was significantly lower than that in the non-extrusion group (p < 0.05). Postoperative persistent knee pain occurred in six cases (6.1%), with four and two cases in the extrusion and non-extrusion groups, respectively. The incidence of postoperative persistent knee pain in the extrusion group was higher than that of the non-extrusion group (p < 0.05). Radiographic assessment showed that the continuity of the femoral and tibial components in the extrusion group was greater than that in the non-extrusion group (p < 0.05). However, there were no differences in pre- and postoperative HKAA, the varus/valgus degree of both femoral and tibial components, and the flexion/extension angles of the femoral component, and the tibial slope also showed no statistical difference (p > 0.05).

Conclusion: For Oxford mobile-bearing UKA, the extrusion of meniscus bearing over 5 mm may increase the incidence of postoperative persistent knee pain, while the improvement of the bearing movement trajectory can effectively reduce this complication.