Patient reported outcome measures (PROMs) as primary and secondary outcomes in total hip and knee arthroplasty randomized controlled trials: a systematic review

BACKGROUND

Significant heterogeneity exists regarding patient reported outcome measures (PROMs) used in total hip (THA) and knee (TKA) arthroplasty randomized controlled trials (RCTs). This study investigates the PROMs used as primary and secondary outcomes in contemporary arthroplasty RCTs.

METHODS

A literature search identified THA and TKA RCTs that were published in top ten impact factor orthopaedic journals from 2017 to 2021. Screening identified 241 trials: 76 THA, 157 TKA, and eight combined. Data were extracted to identify PROMs utilized as either primary or secondary outcomes and the time period of measurement.

RESULTS

Visual Analog Scale (VAS) Pain was the most reported primary PROM in THA (9.2%) and TKA (22.9%) trials. This was followed by Numeric Rating Scale (NRS) Pain (7.9%) and the Harris Hip score (6.6%) in THA trials and NRS Pain (4.5%) and the Knee Society score (4.5%) in TKA trials. Many THA (37.0%) and TKA (52.1%) trials did not clearly specify primary outcome time points. Only pain scales were reported at time points less than one week, while various joint-specific functional outcomes were reported at later time points. As secondary outcomes, the Harris Hip score (28.9%) was most common in THA trials and the Knee Society score (26.1%) was most common in TKA trials. Indeterminate primary or secondary outcomes were reported in 18.2% of studies.

CONCLUSIONS

Contemporary THA and TKA trials exhibit heterogeneity of PROMs as study outcomes after the first postoperative week. Our findings highlight the need for consensus in PROM reporting and better methodological reporting to improve the interpretability of RCT outcomes.

PROSPERO REGISTRATION NUMBER

CRD42022337255.

Stroke History and Time Elapsed are Predictors of Complications in Total Knee Arthroplasty

BACKGROUND

A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors.

METHODS

A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI).

RESULTS

The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067).

CONCLUSIONS

Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk.

Hydroxyapatite-Coated Femoral Stems in Primary Total Hip Arthroplasty: An Updated Meta-Analysis

BACKGROUND

Most primary total hip arthroplasties (THAs) performed in the United States utilize cementless fixation with porous or hydroxyapatite (HA) coating. A previous meta-analysis comparing HA-coated versus non-HA-coated stems in primary THA published in 2013 found no significant difference between the 2. However, an updated analysis of the current literature is needed to assess the potential benefit of HA-coated stems in primary THA.

METHODS

Various libraries were searched through May 2022 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Studies included were randomized controlled trials comparing HA-coated femoral stems to non-HA-coated stems in primary THA. Outcomes included Harris Hip Score (HHS), endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, thigh pain, and heterotopic ossification.

RESULTS

There were significantly fewer revisions for aseptic loosening (P = .004) and decreased postoperative thigh pain (P = .03) for patients who have with HA-coated stems. There was no significant difference in HHS (P = .20), endosteal bone formation (P = .96), radiolucent lines (P = .75), linear wear rate (P = .41), or heterotopic ossification (P = .71) between HA-coated and non-HA-coated stems.

CONCLUSION

We found that HA-coated femoral stems in primary THA led to significantly fewer stem revisions for aseptic loosening and less postoperative thigh pain compared to non-HA-coated stems. These findings suggest HA-coated femoral stems should be preferred over non-HA-coated femoral stems in primary THA.

Evaluation of painful total knee arthroplasty: an approach based on common etiologies for total knee arthroplasty revision

A differential diagnosis with emphasis on the common indications for revision should be utilized in the workup of painful total knee arthroplasty (TKA). The physician should identify the exact etiology of the patient's pain to maximize outcomes from treatment. Evaluation for infection should be completed using the Musculoskeletal Infection Society (MSIS) criteria. When common causes of revision TKA do not appear to be the cause of the pain, less likely causes should be not be ignored. Further advancements such as pressure sensing devices may be able to improve patient satisfaction and decrease the incidence of pain following TKA.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

AIM

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum.

MATERIAL AND METHODS

An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text.

RESULTS

All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound.

CONCLUSIONS

Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

Prediction of suitable outpatient candidates following revision total knee arthroplasty using machine learning

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Methods

Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models.

Results

Of the 5,600 patients included in this study, 342 (6.1%) underwent SDD. The random forest (RF) model performed the best overall, with an internally validated AUC of 0.810. The ten crucial factors favoring SDD in the RF model include operating time, anaesthesia type, age, BMI, American Society of Anesthesiologists grade, race, history of diabetes, rTKA type, sex, and smoking status. Eight of these variables were also found to be significant in the MLR model.

Conclusion

The RF model displayed excellent accuracy and identified clinically important variables for determining candidates for SDD following rTKA. Machine learning techniques such as RF will allow clinicians to accurately risk-stratify their patients preoperatively, in order to optimize resources and improve patient outcomes.

Prediction of Non-Home Discharge Following Total Hip Arthroplasty in Geriatric Patients

Introduction

The majority of total hip arthroplasty (THA) patients are discharged home postoperatively, however, many still require continued medical care. We aimed to identify important characteristics that predict nonhome discharge in geriatric patients undergoing THA using machine learning. We hypothesize that our analyses will identify variables associated with decreased functional status and overall health to be predictive of non-home discharge.

Materials and Methods

Elective, unilateral, THA patients above 65 years of age were isolated in the NSQIP database from 2018-2020. Demographic, pre-operative, and intraoperative variables were analyzed. After splitting the data into training (75%) and validation (25%) data sets, various machine learning models were used to predict non-home discharge. The model with the best area under the curve (AUC) was further assessed to identify the most important variables.

Results

In total, 19,840 geriatric patients undergoing THA were included in the final analyses, of which 5194 (26.2%) were discharged to a non-home setting. The RF model performed the best and identified age above 78 years (OR: 1.08 [1.07, 1.09], P < .0001), as the most important variable when predicting non-home discharge in geriatric patients with THA, followed by severe American Society of Anesthesiologists grade (OR: 1.94 [1.80, 2.10], P < .0001), operation time (OR: 1.01 [1.00, 1.02], P < .0001), anemia (OR: 2.20 [1.87, 2.58], P < .0001), and general anesthesia (OR: 1.64 [1.52, 1.79], P < .0001). Each of these variables was also significant in MLR analysis. The RF model displayed good discrimination with AUC = .831.

Discussion

The RF model revealed clinically important variables for assessing discharge disposition in geriatric patients undergoing THA, with the five most important factors being older age, severe ASA grade, longer operation time, anemia, and general anesthesia.

Conclusions

With the rising emphasis on patient-centered care, incorporating models such as these may allow for preoperative risk factor mitigation and reductions in healthcare expenditure.

Advanced glycation end-product accumulation differs by location and sex in aged osteoarthritic human menisci

OBJECTIVE

There is a clear link between increasing age and meniscus degeneration, leading to increased injury, osteoarthritis (OA) progression, and often total knee replacement. Advanced glycation end-products (AGEs) are non-enzymatic crosslinks and adducts that accumulate in collagen with age, altering tissue mechanics and cell function, ultimately leading to increased injury and inflammation. AGEs, both fluorescent and non-fluorescent, play a central role in age-related degradation of tissues throughout the body; however, little is known about their role in meniscus degeneration. The objective of this study was to characterize changes in aged OA menisci, specifically evaluating zonal AGE accumulation, to gain a better understanding of changes that may lead to age-related meniscal degeneration.

METHOD

Deidentified human menisci (N = 48, 52-84 years old) were obtained from subjects undergoing total knee replacement. Changes in extracellular matrix (ECM) were assessed by gross morphology, confocal analysis, and biochemical assays. Deoxyribonucleic acid (DNA), glycosaminoglycan (GAG), collagen, and AGE accumulation were compared with patient age, zonal region, and patient sex.

RESULTS

There were minimal changes in DNA, GAG, and collagen concentration with age or zone. However, collagen fraying and AGEs increased with age, with more AGEs accumulating in the meniscal horns compared to the central body and in male menisci compared to females.

CONCLUSIONS

Overall, this work provides greater insights into regional changes that occur in human menisci with age and OA. These results suggest AGEs may play a role in the degeneration of the meniscus, with AGEs being a possible target to reduce age-related tears, degeneration, and OA progression.

Antegrade femoral nailing in the lateral decubitus position: a case series, technical tips and review of literature

BACKGROUND

Femoral intramedullary nailing is traditionally performed with the patient supine on a fracture table. We aimed to describe a case series of femoral intramedullary nailing for fracture in the lateral position, with discussion of the operative technique.

METHODS

A retrospective analysis identified 52 patients who underwent femoral intramedullary nailing performed in a lateral position without traction over a 5-year period at a single level 1 trauma center. Medical records were reviewed for demographics, blood loss including need for transfusion, operative duration, complications, length of stay, fracture union, re-operation and death.

RESULTS

There were 24 subtrochanteric, 16 peri-trochanteric and 12 diaphyseal femoral fractures. Mean operative time was 136.2 ± 101.4 min with a mean estimated blood loss of 372.5 ± 349.6 ml. Seventeen patients required blood transfusion. Mean length of stay was 10.3 ± 8.1 days. There were 3 (5.8%) surgical (compartment syndrome, infection and retained drain) and 12 (23.1%) medical complications, with a 30-day mortality rate of 3.8% (2). Mean follow-up was 9.9 ± 8.7 months. The union rate was 94.2% (49) and 3.8% (2) patients required revision fixation (hardware exchange for irritation and exchange nailing for non-union). Discharge destination was home, rehabilitation center and specialized nursing facility in 21 (40.4%), 16 (30.8%) and 15 (28.8%) patients, respectively.

DISCUSSION AND CONCLUSION

Femoral intramedullary nailing in the lateral decubitus position is a useful technique of managing peri-trochanteric, subtrochanteric and diaphyseal femoral fractures. We describe a known technique with technical tips, which has distinct advantages over traditional supine positioning especially in certain patient and fracture types. In addition, operative times, blood loss, length of stay, revision and outcomes were comparable to the literature.

Return to Sports After Total Hip Arthroplasty: An Umbrella Review for Consensus Guidelines

BACKGROUND

Current recommendations on safe return to sports (RTS) after total hip arthroplasty (THA) are subjective and based on studies of varying quality.

PURPOSE

The aim of this study was to synthesize systematic reviews and meta-analyses on post-THA RTS to propose practice guidelines identifying which sports can be resumed, when they can be resumed, and what risks are present.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This umbrella review followed the Joanna Briggs Institute (JBI) protocol and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Embase, Medline, and Cochrane databases were searched. Included studies were either systematic reviews or meta-analyses addressing primary or secondary outcomes. Outcomes of interest included safe sports after THA, time to RTS, prognostic indicators of RTS, reasons patients do not RTS, percentage of patients who RTS, implant complications, and objective classification of sports by impact level. Included reviews had data extracted and were assessed for methodological quality using the JBI protocol. The authors defined RTS as "returning to a sport the patient participated in at any point preoperatively."

RESULTS

Patients demonstrated a trend toward lower-impact sports postoperatively. Sports were classified as low (eg, walking), moderate (eg, downhill skiing), or high impact (eg, soccer). A total of 82% (range, 55%-104%) of patients were able to RTS at a mean time of 6 months (range, 4-7 months). The best prognostic indicator for RTS was previous experience in that sport. The main reason patients did not RTS was surgeon recommendation. Aseptic loosening was the most cited complication after RTS.

CONCLUSION

Most patients are able to return to preoperative levels of low- (eg, walking) and moderate-impact (eg, hiking) sports between 7 and 12 months after THA. Patients planning a return to high-impact (eg, singles tennis) sports should be counseled on the possible risks of traumatic injuries and aseptic loosening and monitored closely.

The Role of Cryotherapy After Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Previous research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM).

METHODS

A strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review.

RESULTS

Opioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs.

CONCLUSION

Cryotherapy's role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.

Cementation in total hip arthroplasty: history, principles, and technique

Total hip arthroplasty (THA) is a remarkably successful operation that has grown rapidly its utilization. Early modern THA constructs as developed by Sir John Charnley featured cemented femoral stems and acetabular components. The technique of cementing components for THA has evolved over time. Modern acetabular preparation requires exposure of the subchondral bone with appropriate cement penetration into the trabecular bone, whereas femoral preparation requires cleaning of the canal, cement restrictor placement, retrograde filling, and pressurization of the cement. When used appropriately, these techniques result in excellent long-term survivorship of implants and are also widely considered to be the ideal method of fixation for hip fractures. The purpose of this article to review the history, properties, techniques, and outcomes of bone cement utilization in THA.

Significant Reduction in Short-Term Complications Following Unicompartmental Versus Total Knee Arthroplasty: A Propensity Score Matched Analysis

BACKGROUND

Total knee arthroplasty (TKA) is a gold standard surgical treatment for end-stage arthritis and unicompartmental knee arthroplasty (UKA) is an alternative for localized disease in appropriate patients. Both have been shown to have equivalent complications in the short-term period. We aimed to explore the differences in 30-day complication rates between UKA and TKA using recent data.

METHODS

Current Procedural Terminology codes identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent primary TKA or UKA from 2014 to 2018. Propensity score matching addressed demographic differences. Rate of any adverse event (AAE) and complications were compared.

RESULTS

We identified 279,852 patients with 270,786 and 9,066 undergoing TKA and UKA. No significant difference was observed in baseline demographics after matching. The AAE rate differed significantly between TKA (5.07%) and UKA (2.38%) cohorts (P < .001). TKA group experienced more wound dehiscence, cerebrovascular accident, postoperative blood transfusion, deep vein thrombosis, and requirement for postoperative intubation. Rate of extended length of stay differed between the TKA (11.35%) and UKA (4.89%) cohorts (P < .001). Accounting for all other variables, preoperative corticosteroid use, bleeding disorder, and chronic obstructive pulmonary disease increased the risk for AAE for both groups. Increasing American Society of Anesthesiologists class also increased the odds for complication proportionally with increasing age and operative time.

CONCLUSION

Contrary to previous data, we found a significantly higher 30-day complication rate in TKA patients. TKA patients had a higher likelihood of having an extended length of stay. Multivariable analysis identified preoperative steroid use, bleeding disorder, and chronic obstructive pulmonary disease as risk factors for developing adverse events for both groups.

LEVEL OF EVIDENCE

Level III.

Clinical Outcomes are Similar Between Graft Types Used in Chronic Patellar Tendon Reconstruction: A Systematic Review

Purpose

To compare clinical outcomes between graft types and techniques used to repair chronic patellar tendon injuries to help surgeons make evidence-based decisions.

Methods

Medline, Embase, and Cochrane libraries were searched through January 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Inclusion criteria were surgical treatment of chronic patellar tendon injury (defined as >6 weeks old), article available in English, and human subjects, minimum 1-year follow-up, and level of evidence I-IV. Studies describing chronic patellar tendon ruptures in the setting of total knee arthroplasty were excluded. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal tools for case reports and case series.

Results

A total of 642 studies were identified through the initial search with 9 studies meeting all inclusion criteria. All studies included were case series encompassing 96 patients with follow-up ranging from 21 months to 7.2 years. Reconstruction techniques included the use of semitendinosus and/or gracilis tendon(s), Achilles tendon, bone-patellar tendon-bone (BTB), or direct repair. The most common graft choice was semitendinosus and/or gracilis tendon(s). Each reconstruction method yielded improvement in respect to range of motion (ROM), extensor lag, quadriceps strength, and patient-reported outcome measures (PROMs). Commonly reported complications were pain and numbness with only one reported instance of graft failure.

Conclusions

In this study, we found that all reconstructive methods described in the literature can produce satisfactory outcomes with improved function, strength, and minimal complications after chronic patellar tendon ruptures. Because of study heterogeneity and low levels of evidence, consensus cannot be reached on a single superior reconstruction method.

Level of Evidence

Level IV, systematic review of level IV studies.

Comparing Revision Total Knee Arthroplasty Stems at a High-Volume Revision Center

Introduction

Hybrid fixation and fully cemented fixation are commonly used in revision total knee arthroplasty (rTKA). These two techniques are typically done based on surgeon preference and one has not demonstrated superiority over the other. The purpose of this study was to examine if there was a difference in survivorship between the two different techniques.

Methods

A retrospective cohort study of all consecutive patients undergoing rTKA (CPT 27487) from January 1, 2011 to January 1, 2018 at a single academic center was performed. Patients were divided into cemented and hybrid rTKA groups with comparison of patient demographic, clinical and radiological outcomes, reoperation, change in post-operative hemoglobin (HgB), and length of stay (LOS).

Results

A total of 133 rTKA for 122 patients were identified: 30.1% in the cemented and 69.9% in the hybrid groups. There was no significant difference in age (p = 0.491), sex (p = 0.250), laterality (p = 0.421), or body mass index (BMI) (p = 0.609) between the two groups. Mean LOS (hybrid 4.13 days, cemented 3.65 days; p = 0.356) and change in Hgb (hybrid 2.95 mg/dL, cemented 2.62mg/dL; p = 0.181) were not statistically different between the groups. Mean follow up for the hybrid (25.4 months, range 2–114 months) and cemented (24.6 months, range 3–75.5 months) rTKA was not statistically significant (p = 0.825). Overall survival rates were 80.9% in the hybrid and 84.6% in the cemented groups (p = 0.642).

Conclusions

Hybrid and fully cemented rTKA techniques have similar survival rates at a minimum followup of 2 years. Additionally, in our cohort, age, gender, and BMI were not associated with failure in either group. Furthermore, we did not observe differences in LOS or change in hemoglobin suggesting early postoperative complications may not differ between cemented and hybrid stemmed groups. Continued long-term research is required for defining the best rTKA technique.

Return to sport post-knee arthroplasty : an umbrella review for consensus guidelines

AIMS

Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA.

METHODS

Systematic reviews and meta-analyses written between 2010 and 2020 were systematically searched. Studies were independently screened by two reviewers and methodology quality was assessed. Variables for analysis included objective classification of which sports are safe to participate in postoperatively, time to return to sport, prognostic indicators of returning, and reasons patients do not.

RESULTS

A total of 410 articles were found, including 58 duplicates. Seven articles meeting inclusion criteria reported that 34% to 100% of patients who underwent TKA or UKA were able to return to sports at 13 weeks and 12 weeks respectively, with UKA patients more likely to do so. Prior experience with the sport was the most significant prognostic indicator for return. These patients were likely to participate in low-impact sports, particularly walking, cycling, golf, and swimming. Moderate-impact sport participation, such as doubles tennis and skiing, may be considered on a case-by-case basis considering the patient's prior experience. There is insufficient long-term data on the risks to return to high-impact sport, such as decreased implant survivorship.

CONCLUSION

There is a consensus that patients can return to low-impact sports following TKA or UKA. Return to moderate-impact sport was dependent on a case-by-case basis, with emphasis on the patient's prior experience in the sport. Return to high-impact sports was not supported. Patients undergoing UKA return to sport one week sooner and with more success than TKA. Future studies are needed to assess long-term outcomes following return to high-impact sports to establish evidence-based recommendations. This review summarizes all available data for the most up-to-date and evidence-based guidelines for returning to sport following TKA and UKA to replace guidelines based on subjective physician survey data. Cite this article: Bone Jt Open 2022;3(3):245-251.

Knee Arthroplasty with Prior Ligamentous Knee Surgery: A Matched Case-Control Study

We aimed to evaluate the timing, operative details, and outcomes of total knee arthroplasty (TKA) in patients with prior ligamentous knee surgery (LKS). All consecutive patients undergoing TKA with prior LKS at a single institution were identified from a large prospectively collected database. Patients were matched on a 2:1 basis according to age, sex, and body mass index to a group of patients without previous LKS undergoing primary TKA. A total of 39 patients with prior LKS and a mean age of 55.6 years (range: 42.8-76.4) were identified and matched with 78 patients without LKS with a mean age of 57.6 years (range: 44.0-79.4) undergoing primary TKA (p = 0.24). Significantly more posterior stabilized implants were used in patients with LKS compared with control patients (29 [74.3%] vs. 27 [34.6%], p < 0.001). In the LKS group, 15 patients (38.4%) required hardware removal. Postoperative complications and rate of further surgery were greater in the LCS group, but the difference was not significant (10.6 vs. 6.4%, p = 0.25). Mean difference in pre- to postoperative knee flexion and clinical outcome scores (12-item Short Form Survey, International Knee Documentation Committee, and Oxford Knee Score) were similar between the two groups, with no cases of loosening or osteolysis. TKA with prior LKS often warranted hardware removal and generally more constrained implants. Those patients with prior LKS undergoing subsequent TKA have higher complication rates and an increased rate of subsequent surgery related to post-TKA stiffness.

Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study.

PURPOSE

To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis.

RESULTS

Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups.

CONCLUSION

The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Enhanced Recovery After Primary Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission.

RESULTS

Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates.

CONCLUSIONS

ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty.

LEVEL OF EVIDENCE

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

Radiographic False Evidence of a Tibial Baseplate Fracture After Total Knee Arthroplasty

Fracture of the tibial baseplate is a rare but dramatic cause of typically late fatigue failure in the setting of loosening after total knee arthroplasty. A 58-year-old female presented 4 months after total knee arthroplasty for evaluation of contralateral knee pain. Plain radiographs of the left knee incidentally suggested the possibility of tibial baseplate fracture despite minimal, expected postoperative symptoms. Subsequent computed tomography imaging demonstrated no confirmatory evidence of component failure or fracture. Malalignment and fatigue fracture are proposed etiologies of baseplate fractures. The presented case illustrates the importance of computed tomography imaging and clinical correlation when a diagnosis of baseplate fracture is suspected to avoid an unnecessary revision surgery.

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review

BACKGROUND

Preoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA.

METHODS

A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria.

RESULTS

A total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285.

CONCLUSIONS

Implementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients' access to surgery.

LEVEL OF EVIDENCE

III, Systematic Review.

Does Adherence to Preoperative Surgical Selection Criteria Reduce the Rate of Prosthetic Joint Infection in Primary and Revision Total Knee Arthroplasties?

Background

There has been recent increased focus on the importance of modifiable risk factors that can affect the risk of potentially avoidable complications such as prosthetic joint infection (PJI). We aimed to assess the relationship between adherence to a preoperative optimization protocol at our institution and its influence on the rate of PJI after primary and revision total knee arthroplasty (TKA).

Methods

A single-institution, retrospective study was conducted on all elective primary and revision TKAs performed over a 2-year period. PJI was diagnosed using the 2011 Musculoskeletal Infection Society criteria. Surgical outcomes and PJI were assessed relative to adherence to preoperative optimization criteria. Compliance was set as a binary variable with any case that did not meet all criteria deemed noncompliant.

Results

A total of 669 TKAs met inclusion criteria, including 510 primary and 159 revision TKAs. Overall compliance was 61.3%. There were 26 PJIs (3.9%) in total. The PJI rate was 1.2% (6) among primary and 14.4% (20) among revision TKAs. The rate of PJI among cases that met the preoperative optimization criteria was 2.4% (5), and the rate among cases that did not was 6.2% (21) (P < .05).

Conclusions

Adherence to preoperative optimization criteria may decrease the incidence of PJI after primary and revision TKA, but further study is needed to confirm the findings of this study.

POSSUM and P-POSSUM Scoring in Hip Fracture Mortalities

Introduction:

Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) are general surgical tools used to efficiently assess mortality and morbidity risk. Data suggest that these tools can be used in hip fracture patients to predict morbidity and mortality; however, it is unclear what score indicates a significant risk on a case-by-case basis. We examined the POSSUM and P-POSSUM scores in a group of hip fracture mortalities in order to assess their accuracy in identification of similar high-risk patients.

Materials and Methods:

Retrospective analysis of all consecutive mortalities in hip fracture patients at a single tertiary care center over 2 years was performed. Patient medical records were examined for baseline demographics, fracture characteristics, surgical interventions, and cause of death. Twelve physiological and 6 operative variables were used to retrospectively calculate POSSUM and P-POSSUM scores at the time of injury.

Results:

Forty-seven hip fracture mortalities were reviewed. Median patient age was 88 years (range: 56-99). Overall, 68.1% (32) underwent surgical intervention. Mean predicted POSSUM morbidity and mortality rates were 73.9% (28%-99%) and 31.1% (5%-83%), respectively. The mean predicted P-POSSUM mortality rate was 26.4% (1%-91%) and 53.2% (25) had a P-POSSUM predicted mortality of >20%. Subgroup analysis demonstrated poor agreement between predicted mortality and observed mortality rate for POSSUM in operative (χ² = 127.5, P < .00001) and nonoperative cohorts (χ² = 14.6, P < .00001), in addition to P-POSSUM operative (χ² = 101.9, P < .00001) and nonoperative (χ² = 11.9, P < .00001) scoring.

Discussion/Conclusion:

Hip fracture patients are at significant risk of both morbidity and mortality. A reliable, replicable, and accurate tool to represent the expected risk of such complications could help facilitate clinical decision-making to determine the optimal level of care. Screening tools such as POSSUM and P-POSSUM have limitations in accurately identifying high-risk hip fracture patients.

Tourniquet and tranexamic acid use in total knee arthroplasty

Background

There is no consensus on how tourniquet and tranexamic acid (TXA) use in total knee arthroplasty (TKA) affect blood transfusion rates and total blood loss. We compared outcome measures and transfusion rates after TKA, with and without the use of tourniquet and TXA.

Methods

A retrospective study of 477 consecutive patients undergoing primary TKA between 2008 and 2013 was performed. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Operative times, hemoglobin levels, blood transfusion rates, complications, and length of stay were assessed. Subanalysis was performed on those patients receiving and not receiving TXA within the TU group.

Results

Mean operative duration was 66.4 minutes in the TA group and 87.5 minutes in the TU group (P < .0001). Mean postoperative drop in hemoglobin was greater in TU group (3.1 g/dL vs 2.8 g/dL, P = .002). The transfusion rate was 9.5% in TA compared with 11.5% in TU patients (P = .46) with comparable mean units transfused (2.6 vs 2.2, P = .30). There was no difference in wound infection (P = .82) and total complication rates (P = .27) between groups. Those patients given TXA had a lower hemoglobin drop (2.6 g/dL vs 3.3 g/dL, P = .04) with similar transfusion (13.3% vs 11%, P = .61) and complication (P = .95) rates.

Conclusions

TU TKA had a greater operative duration and postoperative drop in hemoglobin than TA TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates.

Level of Evidence

Level III, retrospective cohort study.

Does Comanagement of Patients With Hip Fracture Influence 30-Day Outcomes

Introduction:

Comanagement of hip fractures is thought to optimize outcomes for these high-risk patients, but this practice is not universal. We aimed to determine whether comanagement of patients with hip fracture affects 30-day outcomes.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all hip fractures between January 2015 and January 2017, totaling 15 461 patients (144 hospitals). Patients were divided into 3 cohorts: 11 233 comanaged throughout stay (CM), 2537 partially comanaged during stay (PCM), or 1691 not comanaged (NCM), by orthopedic surgeons with medicine physicians or geriatricians. Data collected included demographics, hip fracture type, postoperative outcomes, and length of stay (LOS). Logistic regression and linear regression analyses were performed.

Results:

Both CM and PCM patients were older, with more dementia, poorer mobility, and more comorbidities than NCM patients. Mortality rates were 4.55%, 0.81%, and 0.33% for CM, PCM, and NCM, respectively, and risk-adjusted odds ratios (ORs) were 1.63 (95% confidence interval = 1.22-2.23) and 1.22 (0.87-1.74) for CM and PCM, respectively, compared to NCM. Morbidity rates were 11.06%, 15.45%, and 7.63% for CM, PCM, and NCM, respectively, and ORs were 1.74 (1.41-2.16) and 1.94 (1.57-2.41) for CM and PCM, respectively, compared to NCM. Risk-adjusted mean square LOS was 6.38, 8.80, and 7.23 for CM, PCM, and NC, respectively (P < .01).

Conclusions:

Comanaged patients with hip fracture had poorer cognition, function, and general health, with the shortest LOS. Surprisingly, NCM was associated with reduced morbidity and mortality, which may relate to them being the healthiest patients. Overall, our findings still support orthogeriatric comanagement in this high-risk group to maximize outcomes.

P265 Infective endocarditis:think global, act local:changing trends in infective endocarditis-integrating antibiotic stewardship program: data from developing world

Despite improvements in diagnostic and therapeutic strategies, both the incidence, severity & mortality of Infective Endocarditis (IE) seem to be unchanged.The pattern of  the disease in terms of host, agent & environment changing rapidly.The successful integration of antibiotic stewardship program along with the appropriate use of antibiotic agents has made a huge difference in the treatment strategy & cost reduction in patient care for IE. Materials & Methods: A single centre, retrospective & prospective study done between 2009 to 2018. The diagnosis of infective endocarditis was done as per the modified Duke’s Criteria. 355 patients were analysed and baseline demographic data with echocardiographic, microbiologic,complications, treatment & outcomes noted. All blood cultures processing was done with BACTEC and BacTAlert using standard precautions.Antibiotic stewardship program was initiated since February 2016 as per international protocol. Results: The mean age of the study population was 46.7+-3 years. Predominanlty streptococcus species ( 21.4%) was isolated in the culture.A definite rise in atypical (17.9%) organism was noted in 2018 over the period of study as compared to 2009 : Presence of Burkholderia, Candida, Atypical Mycobacterium spp increased. Despite the advances in diagnostic modalities,there has been no change in mortality associated with IE (10.3%) over the period of 2009-2018. There is a predominantly native Mitral Valve involvement (53.7%) & a definite rise in Prosthetic Valve endocarditis (19.6%) noted in the last 5 years. Conclusion:This study is the largest study & data on Infective Endocarditis so far from a single centre in a developing world with a study population of 355 patients. Risk factors for IE have changed over time.Newer paradigms in treating IE and integration of antibiotic stewardship program has successfully brought down the cost and increased care in this part of the developing world.

Changing trends : Organism Profile in IE Year Strept(%) Staph(%) Entero(%) Atypical(%) 2009 26.2 2.4 7.1 7.1 2011 24 8 12 16 2013 20 10 10 17.5 2015 27.3 12.7 3.6 20 2016 13.6 31.8 4.5 18.2 2017 27.6 13.8 10.3 34.5 2018 21.4 17.9 10.7 17.9

Abstract P265 Figure. Changing Epidemiological trends in IE

The safety and efficacy of neuromodulation using percutaneous electrical nerve stimulation for the management of trigeminal-mediated headshaking in 168 horses

Background

Early results from the use of neuromodulation by percutaneous electrical nerve stimulation for the management of trigeminal‐mediated headshaking in horses were promising but lacked sufficient case numbers and long‐term follow‐up. The neuromodulatory procedure has since been established as EquiPENS™.

Objectives

The aim of this study was to report long‐term results from a larger number of cases and to investigate for predictors of outcome.

Study design

Prospective case series using international, multi‐centre data.

Methods

Eligible cases were horses with a veterinary diagnosis of trigeminal‐mediated headshaking, which received EquiPENS™ neuromodulation at trained centres between August 2013 and November 2017. The standard protocol was an initial three‐procedure course, with additional procedures should a horse go into remission but then relapse. Data collected included signalment, history, diagnostic tests performed, details of any complications, whether horses had gone into remission and the length of remission.

Results

Results were obtained from 168 horses, with 530 procedures. The complication rate was 8.8% of procedures. In all but one case, complications were mild and transient, without self‐trauma. Remission of headshaking following the initial course occurred in 53% (72/136) of horses. Median length of time recorded in remission was 9.5 weeks (range 2 days to 156 weeks ongoing). Where signs recurred, most horses went back into remission following additional procedures, usually for longer than from the previous procedure. No predictors for outcome were determined.

Main limitations

No placebo or control group, owner‐assessed results.

Conclusions

EquiPENS™ neuromodulation can be an effective and safe treatment for the management of trigeminal‐mediated headshaking in some horses. An increased understanding of neuromodulation could help optimise the technique. Advances in treatment for trigeminal‐mediated headshaking will remain limited until there is a greater understanding of the aetiopathogenesis of the condition.

Stress Fractures of the Elbow in the Throwing Athlete: A Systematic Review

Background:

Stress fractures of the elbow are rare in throwing athletes and present a challenge from both a management and rehabilitation perspective. Although the incidence of stress fractures of the elbow is increasing, there is a lack of data in the literature focused on throwers.

Purpose:

To evaluate studies regarding the management and outcomes of stress fractures of the elbow in throwing athletes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was conducted by searching the Scopus, PubMed, and Cochrane Library electronic databases to identify studies reporting on the management and outcomes of stress fractures in overhead-throwing athletes. Management data included nonoperative and operative modalities, and outcome data included return to play, encompassing the timing and level of activity. Studies were excluded if the stress fracture of the elbow was not a result of a sport injury attributed to throwing or if the study failed to report whether an athlete returned to play.

Results:

Fourteen studies met the inclusion criteria and were included in this analysis. There were 52 patients in total (50 male, 2 female) with a mean age of 19.7 years (range, 13-29.1 years). The olecranon was the most common location of the stress fracture (51 patients; 98.1%), followed by the distal humerus (1 patient; 1.9%). The majority of patients (n = 40; 76.9%) were treated operatively. Of the 40 patients who were treated surgically, 14 (35.0%) underwent a period of conservative treatment preoperatively that ultimately failed because of persistent nonunion or continued elbow pain. A total of 50 patients (96.2%) returned to sport either at or above their preinjury level. Of the 2 patients (3.8%) who did not return to sport, 1 did not return because of continued elbow pain postoperatively, and the other was lost to follow-up. Complications occurred in 9 patients (17.3%), all of whom were treated surgically.

Conclusion:

On the basis of this systematic review, the majority of elbow stress fractures were treated operatively and approximately one-third after a period of failed nonoperative management. The return-to-sport rate was high. Further, higher level studies are needed to optimize management and return-to-sport rates in this population.

Pediatric Tibial Shaft Fractures

Tibial shaft fractures are one of the most common pediatric fractures. They require appropriate diagnosis and treatment to minimize complications and optimize outcomes. Diagnosis is clinical and radiological, which can be difficult in a young child or with minimal clinical findings. In addition to acute fracture, Toddler's and stress fractures are important entities. Child abuse must always be considered in a nonambulatory child presenting with an inconsistent history or suspicious concomitant injuries. Treatment is predominantly nonoperative with closed reduction and casting, requiring close clinical and radiological followup until union. Although there is potential for remodeling, this may not be adequate with more significant deformities, thus requiring remanipulation or rarely, operative intervention. This includes flexible intramedullary nailing, Kirschner wire fixation, external fixation, locked intramedullary nailing, and plating. Complications are uncommon but include deformity, growth arrest, nonunion, and compartment syndrome.

Does Obesity Affect Outcomes in Patients Undergoing Innovative Multi-Modal Physical Therapy Following Primary Total Knee Arthroplasty?

INTRODUCTION

Knee stiffness following total knee arthroplasty (TKA) is a common complication, especially in obese patients. The initial, non-operative treatments for this complication includes splinting and physical therapy. If these measures fail, manipulation under anesthesia (MUA) or surgical exploration can be considered to restore range of motion (ROM). However, it is generally desirable to avoid these procedures. For these reasons, newer physical therapy protocols have been developed. However, it is unknown whether these protocols are efficacious for obese patients. Therefore, the purpose of this study was to evaluate and compare: 1) ROM; 2) the rate of MUA; 3) number of physical therapy visits; and 4) costs in patients who underwent innovative multimodal physical therapy (IMPT) and were either obese or non-obese.

MATERIALS AND METHODS

A review of a consecutive series of patients undergoing TKA at a single center within a three-year period was performed. All patients received IMPT post-TKA. Patients were divided into obese (body mass index (BMI >30kg/m2) and non-obese (BMI <30 kg/m2) groups. One-hundred and forty-nine patients underwent TKA and had a mean age of 67 years (range, 42 to 88 years). There were 48 patients in the non-obese group and 101 in the obese group. The obese group was significantly younger (mean, 60 years; range 38 to 54 years vs. mean, 69 years; range, 50 to 88 years), with a similar gender distribution. Comparisons of ROM, MUA, number of physical therapy visits, and costs were performed using Student's t-tests and Chi-square tests as appropriate. Cost-analysis was also performed based on the number of visits to physical therapy (PT).

RESULTS

At latest follow-up, there were no significant differences in mean flexion (mean, 115°, range, 90 to 130° vs. mean, 113°, range 60 to 130°) and extension (mean, 0.81°, range, 0 to 10° vs. 0.54°, range 0 to 10°, p=0.469) between the two groups. The obese group had a 14% (n = 12) rate of MUA compared to 2% (n=1) in the non-obese group (p=0.045). Obese patients had a significantly higher number of mean visits to PT. There was significantly higher mean healthcare costs in the obese (mean, $3,919, range $1,043 to $11,749) as compared to the non-obese (mean, $2,950, range $741 to $7,865) group.

DISCUSSION

Although both cohorts have similar mean ROM at final follow-up, the obese cohort had a significantly higher proportion of patients who underwent MUAs following TKA as compared to non-obese patients, despite IMPT. At latest follow-up, the ROM achieved between the two groups was similar. Obese patients required more PT visits resulting in significantly higher mean healthcare costs.

Pathologists’ Views on Consent for Autopsy

Consent to autopsy is usually obtained by a doctor other than the one who will perform the procedure. There is an argument that, for proper informed consent, a pathologist should participate. We ascertained the views of consultant pathologists in south-east England.

53 (87%) of 61 consultants responded, of whom 50 currently do autopsies. Only 2 at present participate directly in obtaining consent, and 10 of the remaining 48 expressed willingness to do so. The general view was that consent is best obtained by a senior clinician from the team that has looked after the patient.

Pathologists see their primary role as to provide guidance to clinicians. Few see it as their function to obtain consent for autopsy.

Do Press Ganey Scores Correlate With Total Knee Arthroplasty-Specific Outcome Questionnaires in Postsurgical Patients?

BACKGROUND

The purpose of this study was to assess whether Center for Medicaid and Medicare services-implemented satisfaction (Press Ganey [PG]) survey results correlate with established total knee arthroplasty (TKA) assessment tools.

METHODS

Data from 736 patients who underwent TKA and received a PG survey between November 2009 and January 2015 were analyzed. The PG survey overall hospital rating scores were correlated with standardized validated outcome assessment tools for TKA (Short form-12 and 36 Health Survey; Knee Society Score; Western Ontario and McMaster Universities Arthritis Index; University of California, Los Angeles; and visual analog scale) at a mean follow-up of 1154 days post-TKA.

RESULTS

There was no correlation between PG survey overall hospital rating score and the above-mentioned outcome assessment tools.

CONCLUSION

Our study shows that there is no statistically significant relationship between established arthroplasty assessment tools and the PG overall hospital rating. Therefore, PG surveys may not be an appropriate tool to determine reimbursement for orthopedists performing TKAs.

What Influences How Patients Rate Their Hospital Stay After Total Hip Arthroplasty?

PURPOSE

Measuring the effect of operative interventions has been a challenge in orthopaedics. The assessment of patient satisfaction, as measured by the Press Ganey (PG) satisfaction surveys, has gained increasing attention. Our purpose was to determine the factors and patient characteristics that influence patient satisfaction after THA.

MATERIALS AND METHODS

The PG database was queried identifying 692 THA patients (November 2009 to January 2015). A multiple regression analysis was conducted.

RESULTS

Significant influence was found in communication with nurses (p=<0.001), response time of hospital staff (p=0.001), communication with physicians (p=0.002), and hospital environment (p=0.049). Management of pain and communication about medications were not significant for overall hospital rating. There were no differences between PG scores of patients who did and did not have complications.

CONCLUSIONS

Hospital rating was significantly influenced by patients' communication with nurses, response time of hospital staff, and communication with physicians. Recognizing the importance of these elements, can greatly improve patient satisfaction after THA.

Highly Porous Metaphyseal Cones in Revision Total Knee Arthroplasty: A Case Series

Highly porous metaphyseal cones are used for the management of large bone defects in revision total knee arthroplasty. These cones fill defects and allow bony ongrowth while providing several sizing and offset options. In this case series, we evaluated three patients who received these latest generation metaphyseal cones. Specifically, these cases will be explored in detail with respect to history, indications, operative technique, and short-term outcomes. Overall, these newer generation porous coated cones are excellent options for large contained bone loss in the absence of infection, and they have demonstrated good clinical and radiological outcomes at short-term follow-up.

Tantalum Cones in Revision Total Knee Arthroplasty

The best strategy to address large bony defects in revision total knee arthroplasty has yet to be determined. The relatively recent development of porous tantalum cones and their use to address massive bone loss in knee arthroplasty has shown promising short- and intermediate-term results. The purpose of this review is to present the current literature on: (1) basic science of porous tantalum, (2) classification and treatment for bone loss, (3) clinical results, and (4) evolution of newer generation cones.

Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysis

Objectives

The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.

Methods

A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed.

Results

Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009).

Conclusion

This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria.

Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638.

The cost of adverse events from knee surgery in the United Kingdom: an in-depth review of the National Health Service Litigation Authority database

BACKGROUND

There has been a significant rise in the number and value of claims against the National Health Service (NHS), with limited studies on litigation in orthopaedic surgery and none in knee surgery alone. We aimed to examine claims against the NHS involving all aspects of knee surgery with respect to costs and trends.

CLINICAL RELEVANCE

To raise awareness of the reasons for litigation in knee surgery, thus potentially improve patient care and reduce future claims.

METHODS

We analysed the NHS litigation authority (NHSLA) database for all orthopaedic surgery claims reported to the NHSLA between 2005 and 2010, with calculation of litigation success rates and odds ratios for those relating to knee surgery.

RESULTS

There were 515 cases identified from the 4609 orthopaedic cases in the NHSLA database (11.2%): 298 (58%) involving total knee replacements (TKRs), 11 (2%) involving unicondylar knee replacements, and 90 cases (30%) remaining open. The total pay out for closed cases was £10.45 million and amputation following TKR resulted in the highest single pay out. Litigation success rates for claimants were highest for retained drains (100%), incorrect prosthesis/prosthesis size (78%), renal failure (75%), poor outcome requiring further surgery (74%) and malalignment (71%). There were also 60 cases of delayed diagnosis which resulted in pay outs totalling £2.90 million. Based on these data, projected future pay out costs for the open TKR cases were estimated to be £2.71 million.

CONCLUSION

Litigation success rates for TKR were highest following technical errors such as malalignment compared to events less under the surgeon's control, such as infection. The number of claims involving incorrect prosthesis/size continues to be of concern. Despite the increased availability of imaging modalities, missed diagnosis also resulted in substantial pay outs.

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation

PURPOSE

Proximal femoral excision is a salvage procedure for painful chronic hip dislocation in cerebral palsy (CP) patients. The primary objective of this article is to describe our experience of an amplified interposition myoplasty, with appropriate peri-operative pain and tone management strategies, in a cohort of non-ambulatory CP patients with painful chronic hip dislocation. Our secondary objective is to present the clinical outcomes of these patients.

METHODS

We describe our experience in 20 CP patients (25 procedures) at mean 54-month (range 27-169) follow-up with a surgical technique that includes an augmented interposition myoplasty and tone management. The indications for surgery were pain (21 hips), poor sitting tolerance (11) and difficulty with perineal care (8).

RESULTS

The mean age was 22 years (range 10-40) with 11 patients Gross Motor Function Classification Scale (GMFCS) IV and 9 patients GMFCS V. Mean length of stay was 13 days (3-35). One procedure required revision at 12 months. Mean pain score improved from 7.8 (5-10) pre-operatively to 2.8 (1-5) post-operatively (p < 0.001). Sitting tolerance improved in all patients and in 75 % (15) perineal care was easier.

CONCLUSIONS

Our interposition myoplasty technique with individualised pain/tone management has good outcomes in this cohort of patients with multiple co-morbidities.

Surgical interventions for anterior shoulder instability in rugby players: A systematic review

AIM: To systematically evaluate the evidence-based literature on surgical treatment interventions for elite rugby players with anterior shoulder instability.

METHODS: We conducted a systematic review according to the PRISMA guidelines. A literature search was performed in PubMed, EMBASE and Google Scholar using the following search terms: “rugby” and “shoulder” in combination with “instability” or “dislocation”. All articles published from inception of the included data sources to January 1^st 2014 that evaluated surgical treatment of elite rugby players with anterior shoulder instability were examined.

RESULTS: Only five studies were found that met the eligibility criteria. A total of 379 shoulders in 376 elite rugby union and league players were included. All the studies were retrospective cohort or case series studies. The mean Coleman Methodological Score for the 5 studies was 47.4 (poor). Owing to heterogeneity amongst the studies, quantitative synthesis was not possible, however a detailed qualitative synthesis is reported. The overall recurrence rate of instability after surgery was 8.7%, and the mean return to competitive play, where reported, was 13 mo.

CONCLUSION: Arthroscopic stabilization has been performed successfully in acute anterior instability and there is a preference for open Latarjet-type procedures when instability is associated with osseous defects.

Sample size calculations in orthopaedics randomised controlled trials: revisiting research practices

The purpose of this study was to identify how often sample size calculations were reported in recent orthopaedic randomized controlled trials (RCTs) and to determine what proportion of studies that failed to find a significant treatment effect were at risk of type II error. A pre-defined computerized search was performed in MEDLINE to identify RCTs published in 2012 in the 20 highest ranked orthopaedic journals based on impact factor. Data from these studies was used to perform post hoc analysis to determine whether each study was sufficiently powered to detect a small (0.2), medium (0.5) and large (0.8) effect size as defined by Cohen. Sufficient power (1-β) was considered to be 80% and a two-tailed test was performed with an alpha value of 0.05. 120 RCTs were identified using our stated search protocol and just 73 studies (60.80%) described an appropriate sample size calculation. Examination of studies with negative primary outcome revealed that 68 (93.15%) were at risk of type II error for a small treatment effect and only 4 (5.48%) were at risk of type II error for a medium sized treatment effect. Although comparison of the results with existing data from over 10 years ago infers improved practice in sample size calculations within orthopaedic surgery, there remains an ongoing need for improvement of practice. Orthopaedic researchers, as well as journal reviewers and editors have a responsibility to ensure that RCTs conform to standardized methodological guidelines and perform appropriate sample size calculations.

A single-center evaluation of the risk for colonization or bacteremia with piperacillin-tazobactam- and cefepime-resistant bacteria in patients with acute leukemia receiving fluoroquinolone prophylaxis

Fluoroquinolone prophylaxis is indicated to prevent neutropenic fever in patients with acute leukemia. However, fluoroquinolone use has been associated with development of multi-drug-resistant Pseudomonas aeruginosa and extended spectrum β-lactamase producing gram-negative bacilli. Due to a presumed risk of multi-drug resistance associated with fluoroquinolone prophylaxis, patients admitted to our hospital with neutropenic fever receive empiric carbapenem therapy until cultures are negative for 72 h or identification of an organism. Our study seeks to identify the incidence of multi-drug-resistant organism colonization and bacteremia among patients who receive fluoroquinolone prophylaxis and to evaluate duration of empiric carbapenem therapy. A retrospective review of adult patients with acute leukemia receiving a fluoroquinolone as outpatient infection prophylaxis, admitted to our tertiary cancer center for treatment of neutropenic fever was completed. Surveillance and blood cultures were reviewed for antibiotic resistance. Duration of empiric carbapenem therapy was reviewed. One hundred patients and 177 admissions for neutropenic fever were included. Six patients harbored a piperacillin-tazobactam-resistant organism found during routine surveillance. Among these patients, two bacteremias were identified, one of which was a piperacillin-tazobactam-resistant organism. Five bacteremias were identified among 83 patients with negative surveillance cultures. Among the bloodstream infections, five organisms isolated were fluoroquinolone resistant. No cefepime-resistant organism was isolated on surveillance or bloodstream cultures. Adherence to the institution guideline of narrowing antibiotics after 72 h of negative cultures occurred in only 13% of neutropenic fever cases. The average duration of carbapenem therapy in 177 neutropenic fever episodes was 4.4 days. Our findings show that among our patient population, there is a low risk of bacteremia with a piperacillin-tazobactam-resistant or cefepime-resistant organism. However, prompt de-escalation of carbapenem therapy needs to be reiterated within hospital practice.

High methodologic quality but poor applicability: assessment of the AAOS guidelines using the AGREE II instrument

BACKGROUND

The American Academy of Orthopaedic Surgeons (AAOS) is a globally recognized leader in musculoskeletal and orthopaedic education. Clinical guidelines are one important focus of the AAOS' educational efforts. Although their recommendations sometimes generate controversy, a critical appraisal of the overall quality of these guidelines has not, to our knowledge, been reported.

QUESTIONS/PURPOSES

We wished to assess the overall quality of the AAOS guidelines using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument.

METHODS

All 14 guidelines available on the AAOS website as of August 2, 2013 were evaluated. Appraisal was performed by three reviewers, independently, using the AGREE II instrument. This is an internationally recognized and validated assessment tool for evaluating guideline quality. Interrater reliability was calculated and descriptive statistics were performed. Strong interrater reliability was shown using a Spearman's Rho test (correlation coefficient ≥ 0.95).

RESULTS

The overall results for AGREE II domains across all 14 guidelines were: scope and purpose (median score, 95%), stakeholder involvement (median score, 83%), rigor of development (median score, 94%), clarity of presentation (median score, 92%), applicability (median score, 48%), and editorial independence (median score, 79%).

CONCLUSIONS

This study showed that the overall quality of the AAOS guidelines is high, however their applicability was found to be poor. The value of guidelines that have a high quality but that are difficult for clinicians to implement is questionable. Numerous suggestions have been proposed to improve applicability including; health economist involvement in guideline production, implementation of pilot studies and audit to monitor uptake of the guidelines and clinician feedback sessions and barrier analysis studies. Future AAOS guidelines should consider and implement steps that can improve their applicability.

Severe destructive arthritis of the carpometacarpal joint: a diagnosis of exclusion case report

We present a case of severe destruction of the thumb carpometacarpal joint (CMCJ) and surrounding structures on a background of osteoarthritis and Seronegative Rheumatoid arthritis. Imaging studies suggested a soft tissue lesion consistent with Pigmented Villonodular Synovitis (PVNS), Synovial Osteochondromatosis or Giant Cell Tumour (GCT). Due to the possibility of malignant transformation and deteriorating symptoms the mass was excised. Histological analysis of the lesion revealed severe degenerative disease with no evidence of malignancy or infection. This represents an atypical presentation of thumb carpometacarpal joint arthritis, which should be diagnosed once more sinister pathology has been excluded.

Hip resurfacing arthroplasty at a non-specialist centre

INTRODUCTION

Few studies have reported the outcome of hip resurfacing arthroplasty (HRA) with respect to implant characteristics from non-specialist centres. We report the survival, clinical and radiological outcomes of a single surgeon series of HRA with an average follow-up duration of five years.

METHODS

All consecutive HRAs performed by a single surgeon between 2003 and 2011 at a district general hospital were retrospectively examined clinically and radiologically.

RESULTS

A total of 85 patients underwent 109 HRAs (58 male [53.2%] and 51 female patients [46.8%]) with a mean follow-up period of 62 months (range: 12-102 months). The median age was 57 years (range: 25-75 years). The mean acetabular and femoral head component sizes were 54 mm (range: 48-64 mm) and 48 mm (range: 42-58 mm) respectively with a mean acetabular inclination angle of 42.9° (range: 20-75°). The survival rate was 95% with five revisions due to aseptic loosening (n=3) and fracture (n=2): these were predominantly for female patients (n=4), with significantly smaller mean acetabular (51 mm, p=0.04) and femoral (44 mm, p=0.02) implant sizes. Furthermore, they had a higher mean acetabular inclination angle of 48.1° (p=0.74). The mean Oxford hip score was 43.8 (range: 25-48) and the mean University of California Los Angeles (UCLA) activity score was 6.8 (range: 3-10). Radiological findings included heterotopic ossification in 13 (11.9%), radiolucent lines in 6 (5.5%), femoral neck thinning in 2 (1.8%) and femoral neck notching in 5 patients (4.6%).

CONCLUSIONS

We have shown that HRA at a non-specialist centre has short to medium-term outcomes comparable with those at specialist centres. HRA therefore remains a viable option although vigilance is required in case selection and follow-up according to national guidance.

Custom-made cement-linked mega prostheses: a salvage solution for complex periprosthetic femoral fractures

Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.

Implementing the National Hip Fracture Database: An audit of care

BACKGROUND

Hip fractures are common injuries in the elderly, with significant associated morbidity and mortality rates. The National Hip Fracture Database (NHFD) was implemented to audit care according to national standards thus improving its clinical and cost-effectiveness.

PATIENTS AND METHODS

We retrospectively examined the care pathway for all hip fractures after its introduction at our centre over 1 year, with an audit of care according to the BOA-BGS 'Blue Book' guidelines. Data between the first (period 1: initial audit) and second (period 2: re-audit) six months of the study period were compared.

RESULTS

There were 372 patients (28% male, 72% female) in total with 190 in period 1 and 182 in period 2. For all patients, the median age was 85 years (range 33-101) and the median time to surgery was 24.5h (1-519.3), with 251 (67.5%) within 36h. Surgical delay was mainly due to lack of theatre space (37.6%) and medical reasons (54.7%). The median length of stay was 11 days (2-92) and the inpatient mortality rate was 6.2% (23). When comparing the two study periods, there were significantly more patients undergoing falls (p<0.01) and bone protection (p<0.01) assessments in period 2. Lack of theatre space was a significantly less common (p<0.01), with a significantly shorter median time to surgery (p=0.01) and length of stay (p<0.01) in period 2. More patients were discharged to rehabilitation units and the mortality rate was non-significantly lower in period 2 (7.4% vs. 5%). The best practice tariff was met in 45.3% and 70.3% (p<0.001) of patients in periods 1 and 2 respectively providing a total income of £95230.00 (GBP).

CONCLUSIONS

Implementing the NHFD has led to an improvement the quality of hip fracture care according to national guidelines. More patients were assessed by an orthogeriatrician, with a shorter time to surgery and length of stay following re-audit. There is potential for an improvement in mortality rates as well as significant financial income for hospitals.

The ruptured Achilles tendon: a current overview from biology of rupture to treatment

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body yet the aetiology remains poorly understood. Despite the extensively published literature, controversy still surrounds the optimum treatment of complete rupture. Both non-operative management and percutaneous repair are attractive alternatives to open surgery, which carries the highest complication and cost profile. However, the lack of a universally accepted scoring system has limited any evaluation of treatment options. A typical UK district general hospital treats approximately 3 cases of AT rupture a month. It is therefore important for orthopaedic surgeons to correctly diagnose and treat these injuries with respect to the best current evidence-based practice. In this review article, we discuss the relevant pathophysiology and diagnosis of the ruptured AT and summarize the current evidence for treatment.