90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis

Morbidity and Mortality Following Total Hip and Knee Arthroplasty With Spinal Versus General Anesthesia: A Retrospective Analysis

BACKGROUND

The optimal anesthetic mode in total joint arthroplasty (TJA) has yet to be clearly identified. Patients undergoing TJA may recieve spinal anesthesia (SA) or general anesthesia (GA). While arthroplasty literature indicates differences in postoperative morbidity, hip fracture literature does not show clear superiority of SA or GA. The purpose of this study was to further investigate this relationship and determine if there is a significant difference in morbidity and mortality between GA and SA in patients undergoing primary total joint arthroplasty.

METHODS

Patients undergoing primary THA or TKA from February 2007 to February 2021 were retrospectively reviewed, creating four cohorts: THA/GA (n = 1,266), THA/SA (n = 1,084), TKA/GA (n = 882), and THA/SA (n = 2,067). Readmission within 90 days, mortality within 365 days, and thromboembolic events within 30 days postoperatively were compared using logistic regression, controlling for age, body mass index, and Charlson Comorbidity Index.

RESULTS

The odds of experiencing a deep venous thrombosis within 30 days postoperatively were elevated in the analysis of both the THA/GA (odds ratio (OR) = 3.1; 95% confidence interval (CI): 1.5 to 7.0; P = .004) and the TKA/GA (OR = 1.9; 95% CI: 1.2 to 3.0; P = .005) groups. Similarly, the risk of pulmonary embolism as higher in the THA/GA cohort (OR = 3.9; 95% CI: 1.2 to 17.3; P = .04). There were also higher odds of mortality within 365 days postoperatively in THA/GA patients (OR = 4.3; 95% CI: 1.7 to 13.0; P = .004). No other differences existed among TKA patients.

CONCLUSIONS

Based upon these data, both SA and GA are reasonable options for primary TKA with similar risk profiles. However, GA may be associated with higher rates of deep venous thrombosis in TJA and pulmonary embolism in THA. General anesthesia (GA) was also loosely associated with increased mortality within 1 year of THA, but this result should be considered with caution.

LEVEL OF EVIDENCE: 3

Substantial Improvement in Self-Reported Mental Health Following Total Hip Arthroplasty Occurs Independent of Anesthetic Technique

BACKGROUND

The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA.

METHODS

Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups.

RESULTS

Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement.

CONCLUSIONS

Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.

Rasch Analysis of Joint Replacement Version for Hip Disability and Osteoarthritis Outcome in Individuals With Advanced Osteoarthritis of Hip Awaiting Total Hip Arthroplasty Surgery

OBJECTIVE

The objective of this study was to examine measurement properties of the Joint replacement version for Hip Disability and Osteoarthritis Outcome Score (HOOS-JR) using Rasch analysis in patients with osteoarthritis of hip (HOA).

DESIGN

Cross-sectional clinical measurement SETTING: Patient outcomes database at a tertiary care hospital PARTICIPANTS: Convenience sampling of patients with HOA scheduled for total hip arthroplasty (N=327) OUTCOME MEASURES AND ANALYSIS: The data for pre-surgery assessments for patients with HOA were extracted from an existing database. Variables extracted included HOOS-JR scores, demographic information (age, sex), health-related data, and anthropometric variables. The assumptions of Rasch model such as the test of fit, fit residuals, ordering of item thresholds, factor structure, DIF, internal consistency and Pearson separation index were examined for the HOOS-JR scores.

RESULTS

The HOOS-JR showed adequate overall fit to the Rasch model, logically ordered response thresholds, no floor or ceiling effects, and high internal consistency (Cronbach's alpha of 0.91). The HOOS-JR did not satisfy the assumption of unidimensionality, albeit the violation of this assumption was marginal (6.12% over 5%). Person-item threshold distribution (difference between person and item means were equal to 0.92 which was less than 1 logit unit) confirmed that the HOOS-JR scores were well targeted.

CONCLUSIONS

Given that the violation of unidimensionality for HOOS-JR was marginal, we recommend further studies to validate this finding. Results broadly support the use of HOOS-JR for assessing hip health in patients with HOA.

Clinical outcomes of modified direct lateral approach of Hardinge for total hip arthroplasty

The aim of the study was to evaluate a modified direct lateral approach for total hip arthroplasty in terms of clinical and functional outcomes, rate of complications and hospitalization. We retrospectively reviewed the data of 526 patients with THA operated in our department between January 2017 and December 2021. Clinical examination, functional outcome and radiographic evaluation were performed during follow-up. Patients were evaluated at the following time points: preoperatively and postoperatively at 3 days, 6 weeks, 12 weeks and 1 year and we registered surgery related data, complications, Visual Analogue Scale pain score, Harris Hip Score, the Western Ontario McMaster Osteoarthritis Index. Low intraoperative blood loss, short operation time, short hospitalization, early mobilization of the patient and good range of motion imposed the modified direct lateral approach as a valuable procedure for the patients with THA. VAS score evaluated at 3 days and 6 weeks indicated a very good overall postoperative experience. The HHS and Womac scores were evaluated at 6 weeks, 12 weeks and 1 year and showed excellent results. Trendelenburg gait and abductor weakness, traditionally related with direct lateral approach, were not significant statistically and complete reversible. We registered a very low complication rates with good functional outcome. The modified direct lateral approach can lead to superior outcomes, improved quality of life, with reduced intra and postoperative complications rate.

The impact of restricted provision of publicly funded elective hip and knee joints replacement during the COVID-19 pandemic in England

AIMS

Elective hip and knee replacement operations were suspended in April 2020 due to the COVID-19 pandemic. The impact of this suspension and continued disruption to the delivery of joint replacement surgery is still emerging. We describe the impact of the pandemic on the provision of publicly funded elective hip and knee replacement surgery at one teaching hospital in England and on which patients had surgery.

METHODS

We included all elective primary and revision hip and knee replacements performed at one hospital between January 2016 and June 2021. Using data for the years 2016-2019, we estimated the expected number of operations and beds occupied per month in January 2020 to June 2021 using time series linear models (adjusting for season and trend). We compared the predictions with the real data for January 2020 to June 2021 to assess the impact of the pandemic on the provision of elective hip and knee replacements. We compared the length of stay and characteristics (age, gender, number of comorbidities, index of multiple deprivation) of patients who had surgery before the pandemic with those who had surgery during the pandemic.

RESULTS

We included 6,964 elective primary and revision hip and knee replacements between January 2016 and June 2021. Between January 2020 and June 2021 primary hip replacement volume was 59% of predicted, and 47% for primary knee replacements. Revision hip replacement volume was 77% of predicted, and 42% for revision knee replacement. Median length of stay was one day shorter for primary (4 vs 3 days) and revision (6 vs 5 days) operations during the pandemic compared with before. Patients operated on during the pandemic were younger and had slightly more comorbidities than those operated on before the pandemic.

CONCLUSIONS

The restricted provision of elective hip and knee replacements during the COVID-19 pandemic changed the patient casemix, but did not introduce new inequalities in access to these operations. Patients were younger, had more comorbidities, and stayed in hospital for less time than those treated before the pandemic. Approximately half the number of operations were performed during the pandemic than would have been expected and the effect was greatest for revision knee replacements.

What enhances the in-hospital mortality following total hip arthroplasty? A national inpatient sample-based study

PURPOSE

With prolonged life expectancy and advancements in prosthetic designs, the proportion of patients belonging to diverse age groups undergoing total hip arthroplasty (THA) has progressively increased. In this context, the details regarding risk factors associated with mortality after THA, and its prevalence need to be clearly understood. This study sought to identify the possible co-morbidities associated with post-THA mortality.

METHODS

Based on Nationwide Inpatient Sample (NIS) database, patients undergoing THA from 2016 to 2019 (using ICD-10CMP) were identified. The included cohort was stratified into two groups: "early mortality" and "no mortality" groups. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups.

RESULTS

Overall, 337,249 patients underwent THA, among whom, 332 (0.1%) died during their hospital admission ("early mortality" group). The remaining patients were included under "no mortality" group (336,917 patients). There was significantly higher mortality in the patients, who underwent emergent THA (as compared with elective THA: odd's ratio 0.075; p < 0.001). Based on multivariate analysis, presence of liver cirrhosis, chronic kidney disease (CKD) and previous history of organ transplant increased the odds of mortality {odds ratio [Exp (B)]} after THA by 4.66- (p < 0.001), 2.37-fold (p < 0.001) and 1.91-fold (p = 0.04), respectively. Among post-THA complications, acute renal failure (ARF), pulmonary embolism (PE), pneumonia, myocardial infarction (MI), and prosthetic dislocation increased the odds of post-THA mortality by 20.64-fold (p < 0.001), 19.35-fold (p < 0.001), 8.21-fold (p < 0.001), 2.71-fold (p = 0.05) and 2.54-fold (p < 0.001), respectively.

CONCLUSION

THA is a safe surgery with low mortality rate during early post-operative period. Cirrhosis, CKD, and previous history of organ transplant were the most common co-morbidities associated with post-THA mortality. Among post-operative complications, ARF, PE, pneumonia, MI, and prosthetic dislocation substantially enhanced the odds of post-THA mortality.

The use of pre-operative Inferior Vena Cava filters for thromboprophylaxis in ultra-high-risk patients undergoing total hip and knee arthroplasty: a systematic review and narrative analysis

PURPOSE

Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results.

METHODS

A systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients.

RESULTS

Ten studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%).

CONCLUSION

The use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BACKGROUND

This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.

METHODS

A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).

RESULTS

Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.

CONCLUSION

Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

Comparison of mortality rate and septic and aseptic revisions in total hip arthroplasties for osteoarthritis and femoral neck fracture: an analysis of the German Arthroplasty Registry

BACKGROUND

Indications for total hip arthroplasties (THA) differ from primary osteoarthritis (OA), which allows elective surgery through femoral neck fractures (FNF), which require timely surgical care. The aim of this investigation was to compare mortality and revisions in THA for primary OA and FNF.

METHODS

Data collection for this study was performed using the German Arthroplasty Registry (EPRD) with analysis THA for the treatment of FNF and OA. Cases were matched 1:1 according to age, sex, body mass index (BMI), cementation, and the Elixhauser score using Mahalanobis distance matching.

RESULTS

Overall 43,436 cases of THA for the treatment of OA and FNF were analyzed in this study. Mortality was significantly increased in FNF, with 12.6% after 1 year and 36.5% after 5 years compared with 3.0% and 18.7% in OA, respectively (p < 0.0001). The proportion for septic and aseptic revisions was significantly increased in FNF (p < 0.0001). Main causes for an aseptic failure were mechanical complications (OA: 1.1%; FNF: 2.4%; p < 0.0001) and periprosthetic fractures (OA: 0.2%; FNF: 0.4%; p = 0.021). As influencing factors for male patients with septic failure (p < 0.002), increased BMI and Elixhauser comorbidity score and diagnosis of fracture (all p < 0.0001) were identified. For aseptic revision surgeries, BMI, Elixhauser score, and FNF were influencing factors (p < 0.0001), while all cemented and hybrid cemented THA were associated with a risk reduction for aseptic failure within 90 days after surgery (p < 0.0001).

CONCLUSION

In femoral neck fractures treated with THA, a significant higher mortality, as well as septic and aseptic failure rate, was demonstrated compared with prosthesis for the therapy of osteoarthritis. Increased Elixhauser comorbidity score and BMI are the main influencing factors for development of septic or aseptic failure and can represent a potential approach for prevention measures.

LEVEL OF EVIDENCE

Level III, Prognostic.

Does total hip arthroplasty result in intercostal nerve injury? A case report and literature review

Neuropathy in surgical-related locations has received concerns after total hip arthroplasty (THA), while the contralateral intercostal nerve (ICN) injury has not been reported. A 25-year-old female patient with a body mass index (BMI) of 17.9 kg/m² visited the orthopedic outpatient clinic with complaints of progressive left hip pain for 20 days. She was diagnosed with left end-stage hip osteoarthritis and developmental dysplasia of the bilateral hips after radiographs and a detailed history-taking. After painstaking consideration, a cementless THA with the standard posterolateral approach was performed under general anesthesia. The procedure was difficult but successful. Unexpectedly, the numbness and slight tingling in the skin of the right breast, lateral chest wall, and axilla cropped up on the first postoperative day. Following the clinical features and the conclusion of the multidisciplinary discussion, we assume that ICN neuropathy is the diagnosis in this case due to compression of the lateral decubitus position during the operation. Her symptoms completely disappeared after using mecobalamin injection (0.5 mg, intramuscular injection, every other day) for 11 days. The Harris left hip score improved from 39 to 94, and the visual analogue scale from 7 was reduced to 2 on the day of discharge. There were no other complications within the first year after the operation. For THA, we should pay attention to some unexpected complications by virtue of the special position, especially in thin and low-BMI people, which suggested that further comprehensive perioperative nursing measures and the beneficial surgical position and anesthesia type were called for.

Effect of Aspirin vs Enoxaparin on 90-Day Mortality in Patients Undergoing Hip or Knee Arthroplasty: A Secondary Analysis of the CRISTAL Cluster Randomized Trial

Importance

Ischemic heart disease remains the leading cause of mortality following hip and knee arthroplasty. Due to its antiplatelet and cardioprotective properties, aspirin has been proposed as an agent that could reduce mortality when used as venous thromboembolism (VTE) prophylaxis following these procedures.

Objective

To compare aspirin with enoxaparin in reducing 90-day mortality for patients undergoing hip or knee arthroplasty procedures.

Design, Setting, and Participants

This study was a planned secondary analysis of the CRISTAL cluster randomized, crossover, registry-nested trial performed across 31 participating hospitals in Australia between April 20, 2019, and December 18, 2020. The aim of the CRISTAL trial was to determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE following hip or knee arthroplasty. The primary study restricted the analysis to patients undergoing total hip or knee arthroplasty for a diagnosis of osteoarthritis only. This study includes all adult patients (aged ≥18 years) undergoing any hip or knee arthroplasty procedure at participating sites during the course of the trial. Data were analyzed from June 1 to September 6, 2021.

Interventions

Hospitals were randomized to administer all patients oral aspirin (100 mg daily) or subcutaneous enoxaparin (40 mg daily) for 35 days after hip arthroplasty and 14 days after knee arthroplasty procedures.

Main Outcomes and Measures

The primary outcome was mortality within 90 days. The between-group difference in mortality was estimated using cluster summary methods.

Results

A total of 23 458 patients from 31 hospitals were included, with 14 156 patients allocated to aspirin (median [IQR] age, 69 [62-77] years; 7984 [56.4%] female) and 9302 patients allocated to enoxaparin (median [IQR] age, 70 [62-77] years; 5277 [56.7%] female). The mortality rate within 90 days of surgery was 1.67% in the aspirin group and 1.53% in the enoxaparin group (estimated difference, 0.04%; 95% CI, -0.05%-0.42%). For the subgroup of 21 148 patients with a nonfracture diagnosis, the mortality rate was 0.49% in the aspirin group and 0.41% in the enoxaparin group (estimated difference, 0.05%; 95% CI, -0.67% to 0.76%).

Conclusions and Relevance

In this secondary analysis of a cluster randomized trial comparing aspirin with enoxaparin following hip or knee arthroplasty, there was no significant between-group difference in mortality within 90 days when either drug was used for VTE prophylaxis.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12618001879257.

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England : a national population-based cohort study from the National Joint Registry

AIMS

Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England.

METHODS

We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA.

RESULTS

We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018.

CONCLUSION

Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care.Cite this article: Bone Joint J 2022;104-B(9):1052-1059.

Incidence and risk factors associated with venous thromboembolism following primary total hip arthroplasty in low-risk patients when using aspirin for prophylaxis

AIMS

The primary aim was to assess the incidence of venous thromboembolism (VTE) following total hip replacements (THR) in a low-risk patient group when using 150 mg aspirin as the pharmacological component of VTE prophylaxis on discharge. The secondary aim was to identify factors associated with an increased risk of a VTE event in this low-risk group.

PATIENTS AND METHODS

Retrospective review of a consecutive cohort of patients undergoing THR during a 63-month period. Patient demographics, socio-economic status, ASA grade, type of anaesthetic, length of surgery and BMI were recorded. A diagnosis of VTE was assigned to symptomatic patients with positive imaging for a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE) within 8 weeks of surgery. Multivariate logistic regression modeling was used to identify factors associated with VTE after THR.

RESULTS

3880 patients underwent THR during the study period, of which 2740 (71%) were low risk and prescribed aspirin for VTE prophylaxis. There were 34 VTE events, of which 15 were DVTs and 18 were PEs, with 1 patient diagnosed with both. The incidence of VTE was 1.2%, with no VTE-related deaths. Patients incurring a VTE postoperatively were more likely to be male (odds ratio [OR] 2.06, p = 0.022), of older age (OR 0.43, p = 0.047) and were more likely to be socially deprived (OR 0.32, p = 0.006). There was no significant difference with patients given low-molecular-weight heparin (LMWH) as an inpatient prior to discharge on aspirin (p = 0.806), nor any difference with the type of anaesthetic used during surgery (p = 0.719).

CONCLUSIONS

Aspirin is a relatively safe and effective choice for VTE prophylaxis in low-risk patients undergoing THR. Male sex and age >70 years were twice as likely to sustain a VTE and patients from the most deprived socio-economic background are 3 times as likely.

Projections for primary hip and knee replacement surgery up to the year 2060: an analysis based on data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

INTRODUCTION

We estimated the number of primary total hip and knee replacements (THR and TKR) that will need to be performed up to the year 2060.

METHODS

We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the volume of primary THRs (n=94,936) and TKRs (n=100,547) performed in 2018. We projected future numbers of THR and TKR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060.

RESULTS

By 2060, THR and TKR volume would increase from 2018 levels by an estimated 37.7% (n=130,766) and 36.6% (n=137,341), respectively. For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70-79 years (44.6% males, 41.2% females); 80-89 years (112.4% males, 85.6% females); 90 years and older (348.0% males, 198.2% females).

CONCLUSION

By 2060 demand for hip and knee joint replacement is estimated to increase by almost 40%. Demand will be greatest in older patients (70+ years), which will have significant implications for the health service requiring forward planning given that morbidity and resource use is higher in this population. These issues, coupled with two waves of COVID-19, will impact the ability of health services to deliver timely joint replacement to many patients for a number of years, requiring urgent planning.

Revision and 90-day mortality following hip arthroplasty in patients with inflammatory arthritis and ankylosing spondylitis enrolled in the National Joint Registry for England and Wales

AIM

To assess revision rates and postoperative mortality in patients undergoing hip arthroplasty (HA) for inflammatory arthritis compared to hip osteoarthritis (OA).

METHODS

The analysis was conducted among cases of HA that were recorded in the National Joint Registry for England and Wales (NJR) between April 2003 and December 2012 and linked to Office for National Statistics mortality records. Procedures were identified where the indication for surgery was listed as seropositive rheumatoid arthritis (RA), ankylosing spondylitis (AS), other inflammatory arthritis (otherIA), or OA. 5-year revision risk and 90-day postoperative mortality according to indication were compared using Cox regression models adjusted for age, sex, American Society of Anaesthesiologists (ASA) grade, year of operation, implant type, and surgical approach.

RESULTS

The cohort included 1457 HA procedures conducted for RA, 615 for AS, 1000 for otherIA, and 183,108 for OA. When compared with OA, there was no increased revision risk for any form of inflammatory arthritis (adjusted HRs: RA: 0.93 (0.64-1.35); AS: 1.14 (0.73-1.79); otherIA: 1.08 (0.73-1.59)). Postoperative 90-day mortality was increased for RA when compared with OA (adjusted HR: 2.86 (1.68-4.88)), but not for AS (adjusted HR: 1.56 (0.59-4.18)) or otherIA (adjusted HR: 0.64 (0.16-2.55)).

CONCLUSIONS

The revision risk in HA performed for all types of inflammatory arthritis is similar to that for HA performed for OA. The 3-fold increased risk of 90-day mortality in patients with RA compared with OA highlights the need for active management of associated comorbidities in RA patients during the perioperative period.

Neuraxial anaesthesia is associated with improved outcomes and reduced postoperative complications in patients undergoing aseptic revision total hip arthroplasty

BACKGROUND

As the incidence of primary total hip arthroplasty (THA) continues to increase, revision THA (rTHA) is becoming an increasingly common procedure. rTHA is widely regarded as a more challenging procedure, with higher complication rates and increased medical, social and economic burdens when compared to its primary counterpart. Given the complexity of rTHA and the projected increase in incidence of these procedures, patient optimisation is becoming of interest to improve outcomes. Anaesthetic choice has been extensively studied in primary THA as a modifiable risk factor for postoperative outcomes, showing favourable results for neuraxial anaesthesia compared to general anaesthesia. The impact of anaesthetic choice in rTHA has not been studied previously.

METHODS

A retrospective study was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent rTHA between 2014 and 2017 were divided into 3 anaesthesia cohorts: general anaesthesia, neuraxial anaesthesia, and combined general-regional (neuraxial and/or peripheral nerve block) anaesthesia. Univariate and multivariate analyses were used to analyse patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post-hoc analysis.

RESULTS

In total, 5759 patients were identified. Of these, 3551 (61.7%) patients underwent general anaesthesia, 1513 (26.3%) patients underwent neuraxial anaesthesia, and 695 (12.1%) patients underwent combined general-regional anaesthesia. On multivariate analysis, neuraxial anaesthesia was associated with decreased odds for any-one complication (OR 0.635; p < 0.001), perioperative blood transfusion (OR 0.641; p < 0.001), and extended length of stay (OR 0.005; p = 0.005) compared to general anaesthesia.

CONCLUSIONS

Relative to those receiving general anaesthesia, patients undergoing neuraxial anaesthesia are at decreased risk for postoperative complications, perioperative blood transfusions, and extended length of stay. Prospective controlled trials should be conducted to verify these findings.

Prognostic Factors of Clinical and Economic Outcomes of Hip Arthroplasty in a Developing Country: A Multilevel Analysis with a 4-Year Cohort Study

INTRODUCTION

This study is aimed at estimating the 30-day postoperative mortality rate and total costs of the medical episode, as well as determining prognostic factors associated with these outcomes for adult patients who have undergone total hip arthroplasty (THA) in Colombia's contributory health system.

METHODS

This was a retrospective cohort using administrative data and included adult patients enrolled in Colombia's contributory health system who underwent THA between the years 2011 and 2014. Outcomes were 30-day mortality ICU admissions, and the 1-year rate of fractures and revisions as well as the total cost of the medical episode incurred by the third-payer for 90 days following the procedure. Multilevel linear regression models were also generated to determine the prognostic factors associated with the outcomes presented.

RESULTS

The study included 17,289 patients, with an average age of 67 years. Outcome rates were calculated per 100 surgeries, resulting in 2.15 for mortality, 3.41 for ICU admissions, 2.42 for revision hip arthroplasty and 0.62 for periprosthetic fractures. This study found the age and Charlson Comorbidity Index were associated with mortality and complications, and that being female and performing the procedure in the capital city were protective factors. It also found that the median total cost of the medical episode was USD $ USD$2742.161 (p25-p75: 353.092-3291.747). The multivariate model found increasing trends in cost as age and CCI scores rose, and higher costs in the Atlantic region.

CONCLUSIONS

Colombia has higher rates of complications from THA than other countries but lower health system costs. For these patients, age, CCI and the geographic region are factors that are associated with mortality, complications, and health system costs.

Results after arthroscopic treatment of iliopsoas impingement after total hip arthroplasty

BACKGROUND

A cause of groin pain after total hip arthroplasty (THA) is mechanical irritation or impingement of the iliopsoas tendon. The incidence is about 4%. If conservative therapy fails, an arthroscopic release of the iliopsoas tendon can be performed. The aim of the study was to assess the mid-term clinical outcome after arthroscopic release. We hypothesize that good results can be achieved by a minimally invasive endoscopic procedure.

METHODS

Using our in-house database, all patients who received an endoscopic release of the iliopsoas tendon due to mechanical irritation after THA were identified. Inclusion criteria were mechanical irritation of the iliopsoas tendon after cementless THA with minimal acetabular component prominence. Exclusion criteria were marked prominence of the acetabular component and groin pain after THA for any other reason. In these patients, the modified Harris Hip Score (mHHS), the pain level using the numerical analogue scale and the UCLA Activity Score were measured. The mean follow-up period was 7 ± 3.8 (2.6-11.7) years.

RESULTS

25 patients were identified in whom an arthroscopic release of the iliopsoas tendon had been performed since 2007. The data of 20 patients were available at follow-up. The gender ratio was 1:1, the average age at the time of arthroscopy was 59 ± 27.7 (52-78) years. The average interval between THA and arthroscopy was 6.3 ± 4.0 (1.7-15) years. The mHHS showed a significant improvement from preoperative 31.2 ± 9.8 (17.6-47.3) to 82.0 ± 9.8 (46.2-100) points (p = 0.001). The pain level on the NAS decreased significantly from 8.5 ± 1.2 (7-10) to 2.5 ± 1.8 (0-6) points (p = 0.001). The activity level based on the UCLA Activity Score raised from 4.0 ± 2.7 (0-7) to 6.5 ± 1.8 (3-9) (p = 0.09).

CONCLUSION

Mechanical irritation and impingement of the iliopsoas tendon is an important diagnosis to be considered in persistent groin pain after total hip arthroplasty. In failure of non-operative treatment, good clinical results can be achieved with arthroscopic release and the pain level can be significantly reduced.

LEVEL OF EVIDENCE

IV.

Neural network prediction of 30-day mortality following primary total hip arthroplasty

Purpose

The purpose is to utilize an artificial neural network (ANN) model to determine the most important variables in predicting mortality following total hip arthroplasty (THA).

Methods

Patients that underwent primary THA were included from a national database. Demographic, preoperative, and intraoperative variables were analyzed based on their contribution to 30-day mortality with the use of an ANN model.

Results

The five most important factors in predicting mortality following THA were preoperative international normalized ratio, age, body mass index, operative time, and preoperative hematocrit.

Conclusion

ANN modeling represents a novel approach to determining perioperative factors that predict mortality following THA.

A comparison of three strategies to reduce the burden of osteoarthritis: A population-based microsimulation study

Objectives

The purpose of this study was to compare three strategies for reducing population health burden of osteoarthritis (OA): improved pharmacological treatment of OA-related pain, improved access to joint replacement surgery, and prevention of OA by reducing obesity and overweight.

Methods

We applied a validated computer microsimulation model of OA in Canada. The model simulated a Canadian-representative open population aged 20 years and older. Variables in the model included demographics, body mass index, OA diagnosis, OA treatment, mortality, and health-related quality of life. Model parameters were derived from analyses of national surveys, population-based administrative data, a hospital-based cohort study, and the literature. We compared 8 what-if intervention scenarios in terms of disability-adjusted life years (DALYs) relative to base-case, over a wide range of time horizons.

Results

Reductions in DALYs depended on the type of intervention, magnitude of the intervention, and the time horizon. Medical interventions (a targeted increase in the use of painkillers) tended to produce effects quickly and were, therefore, most effective over a short time horizon (a decade). Surgical interventions (increased access to joint replacement) were most effective over a medium time horizon (two decades or longer). Preventive interventions required a substantial change in BMI to generate a significant impact, but produced more reduction in DALYs than treatment strategies over a very long time horizon (several decades).

Conclusions

In this population-based modeling study we assessed the potential impact of three different burden reduction strategies in OA. Data generated by our model may help inform the implementation of strategies to reduce the burden of OA in Canada and elsewhere.

The reasons for and mortality of patients unable to receive reimplantation after resection arthroplasty for chronic hip periprosthetic infection

BACKGROUND

Two-stage exchange arthroplasty is a feasible treatment for chronic PJI (periprosthetic joint infection) of total hip arthroplasty (THA). However, there are large numbers of patients who are unable to ultimately receive reimplantation after resection arthroplasty owing to uncontrolled infection and multiple comorbidities. The purpose of the current study was to identify patient-related risk factors and reasons for being unable to undergo revision THA.

METHODS

Individuals undergoing resection arthroplasty for chronic PJI treatment from 2013 to 2020 at our institution were retrospectively reviewed. A variety of patient comorbidities, laboratory data, isolated pathogens, and follow-up status were collected for analysis.

RESULTS

A total of 84 patients (46 men and 38 women) with a 2.7 ± 2.1-year follow-up were analyzed. Thirty-eight (45.2%) patients eventually underwent revision THA, while the other 46 (54.8%) did not receive reimplantation during follow-up. The patients without receiving reimplantation had higher Charlson comorbidity index (CCI) score (3.1 ± 2.9 versus 1.2 ± 1.5; p = 0.001). Lower cumulative incidence of receiving reimplantation was observed in patients with chronic kidney disease (log-rank test, p = 0.019), anemia (p = 0.011), presence of initial fever (p = 0.030), and oxacillin-resistant strain infection (p = 0.030). The most common reasons for not receiving reimplantation were uncontrolled infection, unstable medical conditions, and death. The patients without reimplantation had a relatively higher mortality rate (log-rank test, p = 0.002).

CONCLUSION

Chronic hip PJI with poor medical conditions or oxacillin-resistant strain infection decreased the chance of undergoing revision surgery. These patients had unfavourable outcomes and a higher mortality rate after resection arthroplasty.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Differences in mortality and complication rates following revision knee arthroplasty performed for urgent versus elective indications

AIMS

To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty.

METHODS

Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort.

RESULTS

A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort.

CONCLUSION

Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J 2021;103-B(10):1578-1585.

What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients

BACKGROUND

This study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts?

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis.

RESULTS

The 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001).

CONCLUSION

The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort.

LEVEL OF EVIDENCE

III.

Obesity paradox in joint replacement for osteoarthritis - truth or paradox?

Obesity is associated with an increased risk of cardiovascular disease (CVD) and other adverse health outcomes. In patients with pre-existing heart failure or coronary heart disease, obese individuals have a more favourable prognosis compared to individuals who are of normal weight. This paradoxical relationship between obesity and CVD has been termed the 'obesity paradox'. This phenomenon has also been observed in patients with other cardiovascular conditions and diseases of the respiratory and renal systems. Taking into consideration the well-established relationship between osteoarthritis (OA) and CVD, emerging evidence shows that overweight and obese individuals undergoing total hip or knee replacement for OA have lower mortality risk compared with normal weight individuals, suggesting an obesity paradox. Factors proposed to explain the obesity paradox include the role of cardiorespiratory fitness ("fat but fit"), the increased amount of lean mass in obese people, additional adipose tissue serving as a metabolic reserve, biases such as reverse causation and confounding by smoking, and the co-existence of older age and specific comorbidities such as CVD. A wealth of evidence suggests that higher levels of fitness are accompanied by prolonged life expectancy across all levels of adiposity and that the increased mortality risk attributed to obesity can be attenuated with increased fitness. For patients about to have joint replacement, improving fitness levels through physical activities or exercises that are attractive and feasible, should be a priority if intentional weight loss is unlikely to be achieved.

A comparison of comorbidity measures for predicting mortality after elective hip and knee replacement: A cohort study of data from the National Joint Registry in England and Wales

Background

The risk of mortality following elective total hip (THR) and knee replacements (KR) may be influenced by patients’ pre-existing comorbidities. There are a variety of scores derived from individual comorbidities that can be used in an attempt to quantify this. The aims of this study were to a) identify which comorbidity score best predicts risk of mortality within 90 days or b) determine which comorbidity score best predicts risk of mortality at other relevant timepoints (30, 45, 120 and 365 days).

Patients and methods

We linked data from the National Joint Registry (NJR) on primary elective hip and knee replacements performed between 2011–2015 with pre-existing conditions recorded in the Hospital Episodes Statistics. We derived comorbidity scores (Charlson Comorbidity Index—CCI, Elixhauser, Hospital Frailty Risk Score—HFRS). We used binary logistic regression models of all-cause mortality within 90-days and within 30, 45, 120 and 365-days of the primary operation using, adjusted for age and gender. We compared the performance of these models in predicting all-cause mortality using the area under the Receiver-operator characteristics curve (AUROC) and the Index of Prediction Accuracy (IPA).

Results

We included 276,594 elective primary THRs and 338,287 elective primary KRs for any indication. Mortality within 90-days was 0.34% (N = 939) after THR and 0.26% (N = 865) after KR. The AUROC for the CCI and Elixhauser scores in models of mortality ranged from 0.78–0.81 after THR and KR, which slightly outperformed models with ASA grade (AUROC = 0.77–0.78). HFRS performed similarly to ASA grade (AUROC = 0.76–0.78). The inclusion of comorbidities prior to the primary operation offers no improvement beyond models with comorbidities at the time of the primary. The discriminative ability of all prediction models was best for mortality within 30 days and worst for mortality within 365 days.

Conclusions

Comorbidity scores add little improvement beyond simpler models with age, gender and ASA grade for predicting mortality within one year after elective hip or knee replacement. The additional patient-specific information required to construct comorbidity scores must be balanced against their prediction gain when considering their utility.

Preoperative Anemia in Primary Arthroplasty Patients-Prevalence, Influence on Outcome, and the Effect of Treatment

BACKGROUND

This study aims to: 1) Determine the prevalence of preoperative anemia in arthroplasty; 2) Assess whether preoperative anemia is associated with inferior outcomes; and 3) Ascertain whether optimization in a dedicated blood management program (BMP) is associated with improved outcomes.

METHODS

All primary arthroplasties performed at an academic, tertiary-care, arthroplasty center between 2012 and 2017 were reviewed. Hemoglobin level obtained in the preoperative assessment clinic was recorded. Patients with anemia were then considered for further review in BMP. Outcomes included improvement in hemoglobin level post-BMP; length of stay; perioperative transfusion; 90-day readmission, complication, and reoperation rates. The effect of preoperative anemia and the effect of treatment at the BMP on outcomes were evaluated through multivariable regression analysis controlling for relevant covariates.

RESULTS

17% of patients (932/5384) were found to have anemia; 115/357 patients who attended the BMP were no longer anemic. Thus, at time of operation, 15% of patients (817/5384) had anemia. Anemic patients were 4.09 times more likely (95% CI: 2.64-6.35) to require a transfusion; 1.42 times more likely (95% CI: 0.99-2.03) to sustain complications and had 19% longer (95% CI: 13%-26%) length of stay. Those who attended the BMP were less likely to receive a transfusion (OR = 0.32, 95% CI: 0.16-0.66), suffer from postoperative complications (OR = 0.30, 95% CI: 0.14-0.63), or require readmission compared with anemic patients not seen in the BMP (OR = 0.25, 95% CI: 0.09-0.71).

CONCLUSIONS

The prevalence of anemia in this arthroplasty cohort was 15%. Preoperative, timely, optimization of anemia should be strongly considered as it is likely to reduce "anemia-associated burden" after arthroplasty.

Prediction of ICU admission after orthopedic surgery in elderly patients

Objectives:

Prediction of ICU admission after surgery are important for rational decision-making for different patients in clinical practice. Little information is available about the risk factors of postoperative ICU admission in elderly patients undergoing orthopedic surgery. This study aimed to identify risk factors and develop a predictive model for postoperative ICU admission in elderly patients undergoing orthopedic surgery.

Methods:

A total of 2826 cases of elderly patients receiving orthopedic surgery from October 2010 to September 2016 were retrospectively collected and analyzed. Logistic regression was used to evaluate the impacts of covariates. Support vector machine (SVM) was employed to develop a predictive model based on all pre-operative covariates and the demographic information.

Results:

There were 256 patients transferred to ICU after surgery. ASA III or IV and emergency surgery were found to be independent risk factors while neuraxial anesthesia and joint surgery were protective factors. In addition, a SVM-based predictive model was developed, which had a sensitivity of 90.99%, a specificity of 99.10% and an area under ROC curve of 0.9678.

Conclusions:

Our study revealed that emergency surgery, anesthesia method, surgery type and ASA grade were risk factors to predict postoperative ICU admission in elderly orthopedic patients.

Does chronic kidney disease affect implant survival after primary hip and knee arthroplasty?

AIMS

To investigate whether chronic kidney disease (CKD) is associated with the risk of all-cause revision or revision due to a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty.

METHODS

This retrospective cohort study comprised 18,979 consecutive hip and knee arthroplasties from a single high-volume academic hospital. At a median of 5.6 years (interquartile range (IQR) 3.5 to 8.1), all deaths and revisions were counted. To overcome the competing risk of death, competing risk analysis using the cumulative incidence function (CIF) was applied to analyze the association between different stages of CKD and revisions. Confounding factors such as diabetes and BMI were considered using either a stratified CIF or the Fine and Gray model.

RESULTS

There were 2,111 deaths (11.1%) and 677 revisions (3.6%) during the follow-up period. PJI was the reason for revision in 162 cases (0.9%). For hip arthroplasty, 3.5% of patients with CKD stage 1 (i.e. normal kidney function, NKF), 3.8% with CKD stage 2, 4.2% with CKD stage 3, and 0% with CKD stage 4 to 5 had undergone revision within eight years. For knee arthroplasty, 4.7% with NKF, 2.7% with CKD stage 2, 2.4% with CKD stage 3, and 7% of CKD stage 4 to 5 had had undergone revision. With the exception of knee arthroplasty patients in whom normal kidney function was associated with a greater probability of all-cause revision, there were no major differences in the rates of all-cause revisions or revisions due to PJIs between different CKD stages. The results remained unchanged when diabetes and BMI were considered.

CONCLUSION

We found no strong evidence that CKD was associated with an increased risk of all-cause or PJI-related revision. Selection bias probably explains the increased amount of all-cause revision operations in knee arthroplasty patients with normal kidney function. The effect of stage 4 to 5 CKD was difficult to evaluate because of the small number of patients. Cite this article: Bone Joint J 2021;103-B(4):689-695.

Fluoroscopically Guided Subacromial Spacer Implantation for Massive Rotator Cuff Tears: Two Years of Prospective Follow-up

Background

Massive rotator cuff tears (MRCTs) are common and have been estimated to account for nearly 40% of all rotator cuff tears. An evolving strategy for management of MRCTs has been the implantation of a degradable subacromial spacer balloon that attempts to restore normal shoulder biomechanics.

Purpose

To assess the safety and efficacy of fluoroscopically guided balloon spacer implantation under local anesthesia in a cohort of patients with 2 years of postoperative follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

The safety and efficacy of using fluoroscopically guided subacromial spacer implantation was assessed in 46 patients. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant and American Shoulder and Elbow Society (ASES) scores.

Results

Overall, 87.5% (35/40) of patients saw clinically significant improvement in the total Constant and ASES scores from 6 weeks postoperatively, with improvement maintained up to 24 months postoperatively.

Conclusion

The data suggest that fluoroscopically guided subacromial spacer implantation under local anesthesia is a low-risk, clinically effective option, especially for the elderly population and those patients who have multiple comorbidities or a contraindication to general anesthesia. Patients undergoing subacromial spacer implantation for the treatment of MRCTs had satisfactory outcomes at 2-year follow-up, with a low rate of complications.

Health technology assessment through Six Sigma Methodology to assess cemented and uncemented protheses in total hip arthroplasty

The purpose of this study is to use Health Technology Assessment (HTA) through the Six Sigma (SS) and DMAIC (Define, Measure, Analyse, Improve, Control) problem-solving strategies for comparing cemented and uncemented prostheses in terms of the costs incurred for Total hip arthroplasty (THA) and the length of hospital stay (LOS). Multinomial logistic regression analysis for modelling the data was also performed. Quantitative parameters extracted from gait analysis, electromyography and computed tomography images were used to compare the approaches, but the analysis did not show statistical significance. The variables regarding costs were studied with the Mann-Whitney and Kruskal-Wallis tests. No statistically significant difference between cemented and uncemented prosthesis for the total cost of LOS was found, but the cost of the surgeon had an influence on the overall expenses, affecting the cemented prosthetic approach. The material costs of surgery for the uncemented prosthesis and the cost of theatre of surgery for the cemented prosthesis were the most influential. Multinomial logistic regression identified the Vastus Lateralis variable as statistically significant. The overall accuracy of the model is 93.0%. The use of SS and DMAIC cycle as tools of HTA proved that the cemented and uncemented approaches for THA have similar costs and LOSy.

Postoperative morbidity and mortality in total joint arthroplasty: Exploring the limits of early discharge

INTRODUCTION

In order to enhance cost-effectiveness, shorter hospital stays have been adopted following hip or knee replacement surgery. This study seeks to describe the incidence of morbidity and mortality, five days after patients were taken to surgery with an expected hospital stay of four days.

METHODS

Utilizing an Institutional Joint Replacement database, a descriptive study was carried out using a retrospective cohort of 1233 procedures in 1100 patients between 2012 and 2016. These were followed up for three months to evaluate morbidity and mortality in the postoperative period.

RESULTS

Complications were classified as minor or major (these were defined as any adverse event that can threaten a patient's life or had the potential to result in readmission). Of the cohort, 18 (1.5%) patient procedures presented one or more major complications. On the first postoperative day 3 major complications occurred (including one death). On the second and third day, 4 major complications were registered each day. On the fourth day after surgery, there were no major complications. On the fifth day 1 major complication was identified. After patient discharge there were 6 major complications reported.

DISCUSSION

The balance between early discharge and out-of-hospital morbidity as well as the frequency of hospital readmission must be the basis to determine whether a patient's hospital stay should be reduced. According to our results, it seems to be safe to shorten hospital stay in young and healthy patients. Furthermore, only orthopedic teams that have minimal rates of outpatient complications and adhere to high standards of care should consider reducing hospital stay.

Preparing for an Era of Episode-Based Care in Total Joint Arthroplasty

With a history of steadily rising healthcare costs, the United States faces an unprecedented set of health and financial challenges. The COVID-19 pandemic will only exacerbate these challenges, and it is of paramount importance to reform and refine health systems to maximize the value of care delivered to the patient. Recent developments related to value improvement in total joint arthroplasty suggest that episode-based payment is likely to become standard practice given the current healthcare environment. Consequently, developing episode-based care models for total joint arthroplasty is in the best interests of surgeons, health systems, and patients. In this article, we review important developments related to value-based care in total joint arthroplasty and present an episode-based framework for delivering high-value, patient-centric care. We examine each phase of a total joint arthroplasty episode-preoperative, acute, post-acute, and follow up-and present several ideas with developing bodies of evidence that can improve the value of care delivered to the patient.

Similar early mortality risk after cemented compared with cementless total hip arthroplasty for primary osteoarthritis: data from 188,606 surgeries in the Nordic Arthroplasty Register Association database

Background and purpose - Current literature indicates no difference in 90-day mortality after cemented compared with cementless total hip arthroplasty (THA). However, previous studies are hampered by potential selection bias and suboptimal adjustment for comorbidity confounding. Therefore, we examined the comorbidity-adjusted mortality up to 90 days after cemented compared with cementless THA performed due to osteoarthritis.Patients and methods - Using the Nordic Arthroplasty Register Association database, 2005-2013, we included 108,572 cemented and 80,034 cementless THA due to osteoarthritis. We calculated the Charlson comorbidity index of each patient based on data from national patient registers. The Kaplan-Meier method was used to estimate unadjusted all-cause mortality. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for 14, 30-, and 90-day mortality comparing cemented with cementless THA, adjusting for age, sex, comorbidity, nation, and year of surgery.Results - Cumulative all-cause mortality within 90 days was 0.41% (CI 0.37-0.46) after cemented and 0.26% (CI 0.22-0.30) after cementless THA. The adjusted HR for cemented vs. cementless fixation was 0.97 (CI 0.79-1.2), and similar risk estimates were obtained for mortality within 14 (adjusted HR 0.91 [CI 0.64-1.3]) and 30 days (adjusted HR 0.94 [CI 0.71-1.3]). We found no clinically relevant differences in mortality between cemented and cementless THA in analyses stratified by age, sex, Charlson comorbidity index, or year of surgery.Interpretation - After adjustment for comorbidity as an important confounder, we observed similar early mortality between the 2 fixation techniques.

Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears achieves satisfactory clinical outcomes in the short and middle of follow-up period: a meta-analysis

PURPOSE

This meta-analysis was performed systematically to evaluate the efficacy of subacromial balloon spacers for patients with massive, irreparable rotator cuff tears.

METHODS

Electronic databases, including Medline/PubMed, Embase and Cochrane Library, were systematically searched to identify studies evaluating the efficacy of subacromial spacers for patients with irreparable or massive rotator cuff tears. Meta-analyses were performed to pool the outcome estimates of interest, such as the total constant score (TCS) and its sub-score (pain, activities of daily living [ADL], range of motion [ROM], and strength), Oxford shoulder score (OSS), American Shoulder and Elbow Society scores (ASES) and numeric rating scale (NRS), as well as different outcomes at different time points in the follow-up period.

RESULTS

Ten studies with a total of 261 patients involving 270 shoulders were deemed viable for inclusion in the meta-analysis. The combined results demonstrated significant improvements in the TCS at the final follow-up (pooled mean difference = 26.4, 95% confidence intervals [CIs] 23.3 to 29.5). A sensitivity analysis and subgroup analysis, which were implemented based on two factors, different follow-up points and sub-scores (pain, ADL, ROM, and strength), revealed a consistent trend. The combined shoulder motion results demonstrated significant improvements in the forward flexion and external rotation (0° abduction) variables rather than in the abduction and external rotation (90° abduction) variables. Additionally, significant improvements in the OSS and ASES and a decrease in the NRS were observed in the middle of the follow-up period.

CONCLUSION

This meta-analysis indicated that subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. Although the short- and middle- term effect is significant, the long-term effect needs to be confirmed by large-sample randomized controlled trial.

LEVEL OF EVIDENCE

IV.

Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases

STUDY OBJECTIVES

To investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type.

DESIGN

Retrospective analysis.

SETTING

Operating room.

PATIENTS

349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%).

INTERVENTIONS

No intervention.

MEASUREMENTS

The effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year.

MAIN RESULTS

The OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31-1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased.

CONCLUSIONS

The OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.

Mortality and Complications in Patients with Metastatic Disease after Primary Total Hip and Total Knee Arthroplasty

BACKGROUND

Although palliative therapies such as radiation are usually performed to improve quality of life in patients with metastatic disease, arthroplasty for joint pain may be indicated in some cases. Therefore, the purpose of this study is to evaluate the 30-day mortality risk, the risk of complications including infection and venous thromboembolic events, and the rate of 30-day reoperations and readmissions in patients with metastatic disease undergoing primary total hip and total knee arthroplasty (THA/TKA).

METHODS

We reviewed the National Surgical Quality Improvement Program database from 2008 to 2018 to evaluate rates of postoperative complications after elective primary THA/TKA in patients with disseminated cancer. After exclusions, 205,007 patients undergoing primary THA and 352,337 undergoing primary TKA were retained for analysis: 942 (0.2%) with disseminated cancer. Chi-square was used to compare proportions between groups. Univariate and multivariate logistic regression was used to model the odds ratio of patients with disseminated cancer compared with those without disseminated cancer.

RESULTS

After adjustment for covariates, patients with disseminated cancer had a higher risk of death (OR: 5.25, 95% CI: 2.47-11.17), any complication (OR: 1.95, 95% CI: 1.63-2.33), deep venous thrombosis (OR: 2.39, 95% CI: 1.32-4.35), pulmonary embolism (OR: 3.07, 95% CI: 1.52-6.17), cardiovascular complications (OR: 2.98, 95% CI: 1.47-6.04), transfusion (OR: 2.21, 95% CI: 1.82-2.69), reoperations (OR: 1.89, 95% CI: 1.28-2.78), readmissions (OR: 2.51, 95% CI: 1.95-3.23), and longer length of stay (4.3 vs 2.7 days).

CONCLUSION

Patients with disseminated cancer have significantly elevated risk of complications after elective primary THA/TKA. Understanding the severity of complications is critical to the risk-benefit analysis that confronts patients and surgeons considering surgery.

LEVEL OF EVIDENCE

II.

Lifetime revision risk for medial unicompartmental knee replacement is lower than expected

PURPOSE

Unicompartmental knee replacement (UKR) is widely considered to be a pre-total knee replacement (TKR) particularly in the young. The implication of this is that it is sensible to do a UKR, even though it will be revised at some stage, as it will delay the need for a TKR. The chance of a UKR being revised during a patient's life time has not previously been calculated. The aim of this study was to estimate this lifetime revision risks for patients of different ages undergoing UKR.

METHODS

Calculations were based on data from a designer series of 1000 medial Oxford UKR with mean 10-year follow up. These UKR were implanted for the recommended indications using the recommended surgical technique. Parametric survival models were developed for patients of different ages based on observed data, and were extrapolated using a Markov model to estimate lifetime revision risk.

RESULTS

The estimated lifetime revision risk reduced with increasing age at surgery. Lifetime revision risk at age 55 was 15% (95% CI 12-19), at 65 it was 11% (8-13), at 75 it was 7% (5-9), and at 85 it was 4% (3-5).

CONCLUSION

Provided UKR is used appropriately, the lifetime revision risk is markedly lower than expected. UKR should be considered to be a definitive knee replacement rather than a Pre-TKR even in the young. These lifetime estimates, alongside established benefits for UKR in speed of recovery, morbidity, mortality and function, can be discussed with appropriate patients when considering whether to implant a UKR or TKR.

LEVEL OF EVIDENCE

III.

The necessity of routine postoperative laboratory tests after total hip arthroplasty for hip fracture in a semi-urgent clinical setting

Background

Recent studies suggest that routine postoperative laboratory tests are not necessary after primary elective total hip arthroplasty (THA). This study aims to evaluate the utility of routine postoperative laboratory tests in patients undergoing THA for hip fracture in a semi-urgent clinical setting.

Materials and methods

This retrospective study included 213 consecutive patients who underwent primary unilateral THA for hip fractures. Patient demographics, clinical information, and laboratory tests were obtained from the electronic medical record system. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory test-related interventions.

Results

A total of 207 patients (97.18%) had abnormal postoperative laboratory results, which were mainly due to anemia (190/213, 89.20%) and hypoalbuminemia (154/213, 72.30%). Overall, 54 patients (25.35%) underwent a clinical intervention, 18 patients received blood transfusion, and 42 patients received albumin supplementation. Factors associated with blood transfusion were long operative time and low preoperative hemoglobin levels. Factors associated with albumin supplementation were long operative time and low preoperative albumin levels. Of the 33 patients with abnormal postoperative creatinine levels, 7 patients underwent a clinical intervention. For electrolyte abnormalities, sodium supplementation was not given for hyponatremia, three patients received potassium supplementation, and one patient received calcium supplementation.

Conclusions

This study demonstrated a high incidence of abnormal postoperative laboratory tests and a significant clinical intervention rate in patients who underwent THA for hip fracture in a semi-urgent clinical setting, which indicates that routine laboratory tests after THA for hip fracture are still necessary for patients with certain risk factors.

Level of Evidence

Level III.

Trial registration Clinical trial registry number ChiCTR1900020690.

The short external rotators dissection during the posterior approach in total hip arthroplasty did not change the blood flow

OBJECTIVES

The posterior approach in total hip arthroplasty (THA) often requires dissection of the short external rotators (SERs), which could increase the postoperative dislocation rate. The reattachment of the dissected SERs has been reported to reduce the dislocation rate, while such repair generally causes progression of muscle atrophy. 1 of the suggested causes of atrophy is reduced blood flow to the repaired SERs. The present study aimed to measure the blood flow of the SERs before dissection (pre-tenotomy) and after reattachment (post-reattachment) during the posterior approach in THA.

METHODS

This prospective study included 26 patients who underwent THA via the posterior approach. A laser-Doppler rheometer was used to measure the blood flow in the following SERs at the time of pre-tenotomy and post-reattachment: the piriformis muscle (PM), superior gemellus (SG), inferior gemellus (IG), obturator internus (OI), and subcutaneous tissue as a control.

RESULTS

The average pre-tenotomy and post-reattachment blood flows (mL/minutes/100 g) were: 1.90 ± 0.28 and 1.92 ± 0.40 in the PM, 1.94 ± 0.20 and 1.99 ± 0.39 in the SG, 1.91 ± 0.21 and 1.94 ± 0.30 in the IG, 1.93 ± 0.22 and 1.98 ± 0.36 in the OI, and 1.94 ± 0.24 and 1.87 ± 0.38 in the subcutaneous tissue. The pre-tenotomy and post-reattachment blood flows did not show significant difference in any muscle.

CONCLUSIONS

Laser-Doppler blood flow measurements showed that the blood flow is preserved, even when the SERs are dissected and reattached in THA via the posterior approach.

Personalized estimation of one-year mortality risk after elective hip or knee arthroplasty for osteoarthritis

AIMS

To develop and validate patient-centred algorithms that estimate individual risk of death over the first year after elective joint arthroplasty surgery for osteoarthritis.

METHODS

A total of 763,213 hip and knee joint arthroplasty episodes recorded in the National Joint Registry for England and Wales (NJR) and 105,407 episodes from the Norwegian Arthroplasty Register were used to model individual mortality risk over the first year after surgery using flexible parametric survival regression.

RESULTS

The one-year mortality rates in the NJR were 10.8 and 8.9 per 1,000 patient-years after hip and knee arthroplasty, respectively. The Norwegian mortality rates were 9.1 and 6.0 per 1,000 patient-years, respectively. The strongest predictors of death in the final models were age, sex, body mass index, and American Society of Anesthesiologists grade. Exposure variables related to the intervention, with the exception of knee arthroplasty type, did not add discrimination over patient factors alone. Discrimination was good in both cohorts, with c-indices above 0.76 for the hip and above 0.70 for the knee. Time-dependent Brier scores indicated appropriate estimation of the mortality rate (≤ 0.01, all models).

CONCLUSION

Simple demographic and clinical information may be used to calculate an individualized estimation for one-year mortality risk after hip or knee arthroplasty (https://jointcalc.shef.ac.uk). These models may be used to provide patients with an estimate of the risk of mortality after joint arthroplasty. Cite this article: Bone Joint Res 2020;9(11):808-820.

Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry

Background

Total hip and total knee arthroplasty (THA/TKA) are increasing in incidence annually. While these procedures are effective in improving pain and function, there is a risk of complications.

Methods

Using data from an arthroplasty registry, we described complication rates including reasons for reoperation and readmission from the acute period to six months following THA and TKA in an Australian context. Data collection at 6 months was conducted via telephone interview, and included patient-reported complications such as joint stiffness, swelling and paraesthesia. We used logistic regression to identify risk factors for complications.

Results

In the 8444 procedures included for analysis, major complications were reported by 9.5 and 14.4% of THA and TKA patients, respectively, whilst minor complications were reported by 34.0 and 46.6% of THA and TKA patients, respectively. Overall complications rates were 39.7 and 53.6% for THA and TKA patients, respectively. In THA patients, factors associated with increased risk for complications included increased BMI, previous THA and bilateral surgery, whereas in TKA patient factors were heart disease, neurological disease, and pre-operative back pain and arthritis in a separate joint. Female gender and previous TKA were identified as protective factors for minor complications in TKA patients.

Conclusion

We found moderate rates of major and high rates of minor postoperative complications following THA and TKA in Australia and have identified several patient factors associated with these complications. Efforts should be focused on identifying patients with higher risk and optimising pre- and post-operative care to reduce the rates of these complications.

Is Aspirin as Effective as the Newer Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Total Hip and Knee Arthroplasty? An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BACKGROUND

Few studies have compared aspirin with direct oral anticoagulants (DOACs) (DOACs = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis after THA and TKA using the world's largest joint arthroplasty registry.

METHODS

We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THA and TKA patients. Patients receiving aspirin were matched separately to patients receiving direct thrombin inhibitors and factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events.

RESULTS

After THA, there was a significantly lower risk of VTE associated with the use of direct thrombin inhibitors (0.44%; odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.55-0.87; P = .002) and factor Xa inhibitors (0.37%; OR, 0.63; 95% CI, 0.47-0.85; P = .003) compared with aspirin (0.63%). After THA, direct thrombin inhibitors (coefficient, -0.37 days; 95% CI, -0.43 to -0.31; P < .001) and factor Xa inhibitors (coefficient, -0.80 days; 95% CI, -0.87 to -0.74; P < .001) were associated with a reduced length of stay compared with aspirin. Similar findings for both outcomes were observed after TKA. Compared with aspirin, DOACs were not associated with an increase in the risk of short-term revision surgery, reoperation, major hemorrhage, wound disruption, surgical site infection, and mortality.

CONCLUSION

After THA and TKA, DOACs were associated with a reduced risk of VTE compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs were not associated with an increase in the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin.

JointCalc: A web-based personalised patient decision support tool for joint replacement

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JointCalc is the first complete web decision support tool for joint replacement.

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User-centred design helps avoid common health information system design.

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Modern software production methods synergise with and enable user-centred design.

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JointCalc implementation supports claims of high efficiency of eHealth.

Background and purpose

Health information systems (HIS) are expected to be effective and efficient in improving healthcare services, but empirical observation of HIS reveals that most perform poorly in terms of these metrics. Theoretical factors of HIS performance are widely studied, and solutions to mitigate poor performance have been proposed. In this paper we implement effective methods to eliminate some common drawbacks of HIS design and demonstrate the synergy between the methods. JointCalc, the first comprehensive patient-facing web-based decision support tool for joint replacement, is used as a case study for this purpose.

Methods and results

User-centred design and thorough end-user involvement are employed throughout the design and development of JointCalc. This is supported by modern software production paradigms, including continuous integration/continuous development, agile and service-oriented architecture. The adopted methods result in a user-approved application delivered well within the scope of project.

Conclusion

This work supports the claims of high potential efficiency of HIS. The methods identified are shown to be applicable in the production of an effective HIS whilst aiding development efficiency.

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Total hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice.

METHODS

A total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods.

RESULTS

Unadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P < 0·001) and trans-trochanteric approaches (HRR 1.48 [95% CI 1.14,1.91] P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01-1.30] P = 0.029).

CONCLUSIONS

Lateral approaches for THR are associated with worse outcomes, including more deaths and revisions, than the posterior approach. We recommend the posterior approach should be considered the current standard approach for THR. Large well-designed studies are needed to assess any potential benefits from using minimally invasive posterior approaches and the conventional anterior approach.

Early Mortality after Radical Radiotherapy in Head and Neck Cancer - A Nationwide Analysis from the Danish Head and Neck Cancer Group (DAHANCA) Database

AIMS

Curative-intent radiotherapy (RT) or chemoradiation (CRT) of squamous cell carcinoma of the head and neck (HNSCC) produces high survival rates, but is associated with substantial toxicity. However, there are no commonly accepted quality metrics for early mortality in radiation oncology. To assess the applicability of early mortality as a clinical quality indicator, this study investigated the temporal distribution, risk factors and trends of 90- and 180-day overall and non-cancer mortality in a nationwide cohort of HNSCC patients treated with RT/CRT.

MATERIALS AND METHODS

Information on all HNSCC patients treated with curative-intent RT/CRT in Denmark between 2000 and 2017 was obtained from the national Danish Head and Neck Cancer Group clinical database. Deaths in patients with residual or recurrent disease after RT/CRT were classified as cancer-related. Possible risk factors were investigated using logistic regression analysis.

RESULTS

Data from 11 419 patients were extracted. In total, 90- and 180-day mortality risks were 3.1% and 7.1%, respectively. There was a uniform temporal distribution of 180-day mortality. In multivariable analysis, increasing age, stage, performance status, earlier treatment year and hypopharyngeal cancer were significantly associated with an increased risk (P < 0.05). Risk factor estimates were comparable for 90- versus 180-day mortality as well as for overall versus non-cancer mortality. Between 2000 and 2017 there was a significant decrease in 180-day mortality, which was driven by a reduction in cancer-related events.

CONCLUSION

The distribution of 180-day overall and non-cancer mortality did not indicate a well-defined early high-risk period. Moreover, risk factor estimates were highly similar across risk periods and groups. Taken together, our findings question the applicability of early mortality as a standard metric for treatment-associated toxicity.

The Phenomenon of "Obesity Paradox" in Neck of Femur Fractures

Objective

To determine the association of body mass index (BMI) with 30 days and 1-year mortality outcomes of orthopedic elderly patients after hip fracture surgery.

Methods

This is prospective study conducted at Department of Orthopaedics, at a tertiary care public sector hospital in Karachi between Jan-2016 to Jan-2018. In this short follow-up study, we included the data of 490 patients, who were operated for neck of femur fractures in a public sector tertiary care hospital between Jan-2016 to Jan-2018. Patients were divided into different categories on the basis of BMI; BMI <20 Kg.m^-2 underweight, 20-24.99 Kg.m^-2 normal weight, BMI 25-29.99 Kg.m^-2 overweight, ≥30 obese. Mortality at 30 days and 1-year mortality were primary study end-points.

Results

Rate of re-admission within 30 days, major adverse cardiovascular events (MACE) within 30 days and 30 days mortality was high in underweight and lowest in obese patients. Thirty-day mortality rate was 2.7% in underweight, 1.3% in normal weight, 0.64% in over-weight and 0.0% in obese patients but this was not significant statistically (p-value 0.29). One-year mortality rate was significantly high in under-weight patients, 34.2%, 25.9% in normal weight, 21.4% in overweight and only 14.5% in obese patients (p-value 0.009). Age ≥ 65 years (odds ratio 0.40 (0.26-0.63), and ASA III-IV (odds ratio; 0.27 (0.16-0.45) are also significant risk factors of 1-year mortality.

Conclusion

BMI classification can serve as an important indicator of adverse early outcomes after hip fracture surgery. Over-weight and obese patients have better survival outcomes and have lower 1-year mortality rate.

Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Regional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world's largest joint replacement registry.

METHODS

We studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes.

RESULTS

Length of stay was reduced with regional anesthesia compared with general anesthesia (THR = -0.49 days, 95% confidence interval [CI] = -0.51 to -0.47 days, P < .001; TKR = -0.47 days, CI = -0.49 to -0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality.

CONCLUSION

Regional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.