Functional and Cost Audit of Primary Total Knee Arthroplasty in Public vs Private Hospitals: A Retrospective Cohort Study

BACKGROUND

Government funded hospitals are believed to be stigmatised with 'substandard care' and constant fear of infection. The aim of this study is to compare the results and direct expenditure incurred for total knee arthroplasty (TKA) done at a government funded public teaching hospital with an economy packaged private hospital in India.

MATERIALS AND METHODS

A review of electronic and physical records of the patients operated by the senior author for primary TKA at a government funded hospital and a private hospital spanning 2007 to 2019 was done. A retrospective cohort study was designed matching the implant design and the ASA grade of the patients. Knee injury and Osteoarthritis Outcome Score (KOOS), Hospital for Special Surgery score (HSS), Knee Society Score (KSS) at 2 years follow-up were the primary outcome parameters. The retrieved data describing the cost of surgery and perioperative complications were analyzed. The confounders were minimized by including only the surgeries performed by the author, using the same instruments and implants in similar operating theatre environments.

RESULTS

This study involved two cohorts comprising 280 patients each, with no differences in gender, ASA grade and primary diagnosis. There was no significant difference in the 2-year HSS, KSS and KOOS score between the two groups. The 2-year cumulative incidence of major and minor complications in both the study cohorts showed no significant difference. The mean cost of an uncomplicated primary TKA (2019) in government hospital was INR. 85,927; 39.476% of that required in a private setup (INR. 2,17,667).

CONCLUSION

Affordable TKA package in a government funded hospital can produce results comparable to that in a private hospital setup at a reasonably lower cost without increasing the complication rates.

India Joining the World of Hip and Knee Registries: Present Status-A Leap Forward

BACKGROUND

The number of joint replacements in India is set to grow at the highest rate in the world from 2020 to 2026. It is high time for India to have an efficient and credible registry to help curtail the clinical impact of implant failure at a very early stage by prompt reporting.

METHODS

Indian Joint Registry has been established by ISHKS with new data forms for reporting. These new detailed forms record, in addition to previous form, component-wise details of implants. Additional useful features include Linking with unique ID like PAN or Aadhaar, thromboprophylaxis, untoward intra-operative event, IJR consent and type of anaesthesia.

RESULTS

There were 712 registered surgeons in IJR database till June 2020. Total TKRs being reported to registry increased from 1019 in 2006 to 27,000 in 2019. Majority of the patients (98.5%) were diagnosed with osteoarthritis knee. Company-wise distribution unveils that Johnson & Johnson DePuy represents the highest implant usage at over 37%. There has been increased utilisation of uncemented THR over cemented THR from 2006 to 2019. Dual-mobility THRs have gained ground as surgeon preference for the choice of implant.

CONCLUSION

Effective use of quality registries can lead to better health outcomes at a lower cost for the society. An effective, responsive and sustainable registry in India offers many benefits and should be considered as a key objective. Making the registry function in India successfully will undoubtedly require multi-pronged efforts, but can deliver many benefits both to the patient and to the nation as a whole.

What have we learned from 100% success of press fit condylar rotating platform posterior stabilized knees?: A 5-10 years followup by a nondesigner

BACKGROUND

Total joint arthroplasties of the hip and knee represent a remarkable feat of modern medicine in terms of reducing pain and restoring function to millions of patients afflicted with severe arthritis. Oftentimes, the performance and longevity of new implants and devices are based on limited data. This is the first study by a non-designer on the press fit condylar rotating platform posterior stabilized (PFC-RP-PS) design with 100' success. This has a relevance, vis-á -vis bias that one may have in terms of reproducibility of technique and funding from the manufacturer. We associate our excellent mid-term results to intra operative technical aspects and stringent intra operative exclusion criteria.

MATERIALS AND METHODS

Our study includes a cohort of 121 selected knees operated between January 2003 and October 2010. We used cemented, posterior stabilized (PS), mobile bearing (MB), and RP prosthesis from the same manufacturer in all these 121 knees. The patients were evaluated bi-annually with the calculation of their Knee Society Scores (KSS) and a radiological assessment for loosening/osteolysis.

RESULTS

120 knees were available for followup. The average Knee Society clinical and functional scores, respectively, were 27 points and 40 points preoperatively and 93 points and 95 points postoperatively. This indicates a mean increase of about 71' in the clinical score and about 58' in the functional score, which is statistically significant. The mean postoperative flexion was 124°, a mean increase of 23° from the preoperative flexion of 101°. There were no revisions (Kaplan--Meier survivorship of 100').

CONCLUSIONS

We feel durable and reproducible results of PFC-RP-PS design knees are very technique sensitive. The way ahead with the PFC-RP-PS knees looks promising when the exclusion criteria for this design are strictly met. Coming from a non-designer, this study acquires a higher degree of relevance without any designer's or manufacturer's bias.

Effect of total knee arthroplasty on type II diabetes mellitus and hypertension: A prospective study

CONTEXT

Advanced osteoarthritis of knee joint if bilateral, severely restricts patient mobility. This acts as an aggravating factor for pre existing comorbid elements of metabolical syndrome (MS) like Type II diabetes mellitus and hypertension as patients are unable to carry out therapeutic walks. Successfully implanted total knee arthroplasty (TKA) increases physical activity and enables to carry out therapeutic walks thus may help in better control of type II diabetes mellitus and hypertension. The objective of this prospective study was to find whether TKA for osteoarthritis knee had any effect to improve blood glucose levels and reduce blood pressure.

MATERIALS AND METHODS

A prospective study was done in which patients operated for tricompartmental osteoarthritis of knee with associated comorbidities like Type II diabetes mellitus or hypertension during a period of 2008 and 2009 were studied. One hundred and twenty patients were enrolled (55 diabetics, 65 hypertensives) who met our inclusion criteria. Preoperative knee society score, lower extremity activity scale fasting blood glucose level and systolic and diastolic blood pressure were compared with one year followup values. The KSS and LEAS scores were analysed by the Wilcoxon signed ranked test, while the fasting blood glucose (FBG) levels and systolic and diastolic blood pressure levels were analysed by paired 't' test.

RESULTS

The reduction of systolic blood pressure by 8 mmHg (t = 5.6, P value < 0.05) and diastolic blood pressure by 6 mmHg (t = 7.6, P value < 0.05) was recorded which was statistically significant. However, no statistically significant effect on fasting blood glucose levels was observed (t = -0.77, P value = 0.442). KSS improved in DM from preoperative 29 to 86 and LEAS improved from 6.7 to 11.3.

CONCLUSIONS

Authors are of the opinion that successful total knee replacement results in increased physical activity and reduces blood pressure (systolic and diastolic) in hypertensives. However, the same is not seen in blood glucose level. Increased physical activity and reduced dependence on NSAIDS postoperatively, may be contributing in reduction of systolic and diastolic blood pressure. Further studies in this aspect are necessary.

ISHKS joint registry: A preliminary report

BACKGROUND

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are the most widely practiced surgical options for arthritis all over the world and its application is rising in India. Indian Society of Hip and Knee Surgeons (ISHKS) has established a joints registry and has been collecting data for last 6 years.

MATERIALS & METHODS

All members of ISHKS are encouraged to actively participate in the registry. A simple two page knee and hip form can be downloaded from the website www.ishks.com. The information collected includes patient demographics, indication for surgery, implant details and in case of revision arthroplasty: the details of implants removed and the cause of failure of primary arthroplasty. These forms are mailed to the central registry office and the data is fed in computerized registry. Data collection started in October 2006.

RESULTS

Joint registry is a very important initiative of ISHKS and till date, have data of 34,478 TKAs and 3604 THAs, contributed by 42 surgeons across India. Some important observations have emerged. Data of 34,478 TKAs was assessed: These included 8612 males (25%) and 25,866 females (75%). Average age was 64.4 years (Osteoarthritis range: 45 to 88 years; Rheumatoid arthritis range: 22 to 74 years). Average body mass index was 29.1 (Range: 18.1 to 42.9). The indication for TKA was osteoarthritis in 33,444 (97%) and rheumatoid arthritis in 759 (2.2%). Total of 3604 THA procedures were recorded. These included 2162 (60%) male patients and 1442 (40%) female patients. Average age was 52 years (Range 17 to 85 years) and average BMI was 25.8 (Range: 17.3 to 38.5). The indications for THA was AVN in 49%.

CONCLUSION

The registry will become more meaningful in years to come. Active participation of all arthroplasty surgeons across India is vital for the success of the joints registry.

Computed tomographic evaluation of femoral component rotation in total knee arthroplasty

BACKGROUND

Optimal femoral component rotational alignment in total knee arthroplasty (TKA) is crucial to establish a balanced knee reconstruction. Unbalanced knees can lead to instability, patellofemoral problems, persistent pain, stiffness, and generally poorer outcomes including early failure. Intraoperative techniques to achieve this optimal femoral component rotation include the use of the transepicondylar axis (TEA), the posterior-condylar-cut-parallel-to-the-tibial-cut (PCCPTC) technique and the anteroposterior axis technique (Whiteside's line). The purpose of this study was to compare the PCCPTC technique to the TEA technique using computed tomography (CT) scans to assess femoral component rotational alignment.

MATERIALS AND METHODS

This study used postoperative CT scans to compare the degree of femoral component rotation obtained with the use of PCCPTC technique and the TEA. The femoral component rotation of 30 TKA was measured on postoperative CT scans the angle of deviation between the two lines radiographic trans-epicondylar axis (rTEA) and femoral prosthesis posterior condylar line (FPPCL) was determined. This angle represented the rotation of the femoral component relative to the true rTEA.

RESULTS

The degree of rotation measured 2.67 ± 1.11 degrees in the PCCPTC group and 5.60 ± 1.64 degrees in the TEA group.

CONCLUSION

The use of the TEA technique for determining rotational alignment in TKR results in excessive external rotation of the femoral component compared to the PCCPTC technique.

Bilateral multiligament injury of knee caused by entangled dupatta

We report a rare case of bilateral multiligament knee injury in an 18-year-old female employed in garment industry. Patient was wearing salwar kameez and dupatta while operating an electric laundry machine. In this case we discuss a peculiar mechanism of injury caused due to wearing dupatta near working site and suggest simple preventive measures.

Total knee arthroplasty: Limb length discrepancy and functional outcome

BACKGROUND

Limb length discrepancy and its effects on patient function have been discussed in depth in the literature with respect to hip arthroplasty but there are few studies that have examined the effect on function of limb length discrepency following total knee arthroplasty (TKA). The aim of this study was to determine whether limb length discrepancy after TKA in patients with bilateral osteoarthritis of knee with varus deformity affects functional outcome.

MATERIALS AND METHODS

Fifty-four patients with bilateral osteoarthritis of knee with varus deformity, who were operated for total knee arthroplasty from 1996 to 2008, were reviewed retrospectively. The patients were divided into two groups. Thirty patients (mean age 64 years) were operated for unilateral TKA and thirty patients (mean age 65.8 years) were operated for bilateral total knee arthroplasty. Six patients underwent staged surgery and were included in both groups as the time interval between the two surgeries was more than the minimum 6-month follow-up period specified for inclusion in the study. The limb length discrepancy was measured and statistically correlated with the functional component of the Knee Society Score.

RESULT

In the unilateral group (n=30), the mean limb length discrepancy was 1.53 cm (range: 0-3 cm) and the mean functional score was 73 (range: 45-100). In the bilateral group (n=30), the mean limb length discrepancy was 0.5 cm (range: 0-2 cm) and the mean functional score was 80.67 (range: 0-100). A statistically significant negative correlation was found between limb length discrepancy and functional score in the unilateral group (Spearman correlation coefficient, r =-0.52, P=0.006), while no statistically significant correlation was found in the bilateral group (Spearman correlation coefficient, r = -0.141, P=0.458).

CONCLUSION

Limb length discrepancy affects functional outcome after total knee arthroplasty, especially so in patients of bilateral osteoarthritis with varus deformity undergoing surgery of only one knee.

Silastic replacement of metacarpal after resection of giant cell tumour. A case report

Giant cell tumours are aggressive lesions, albeit benign. Lesions in the hand, especially those arising from metacarpals require resection with adequate margins and definitive structural reconstructions to ensure preservation of hand architecture, function and cosmesis. Almost all the described reconstructive procedures require a stump of tumour free metacarpal base after resection, for reconstruction of the metacarpal. This report describes replacement of the entire metacarpal with a silastic prosthesis, in a case of giant cell tumour involving the entire metacarpal head and shaft to within 7 mm of the base.

An age- and sex-controlled matched pair analysis of T scores in ethnic Indians with hip fractures

OBJECTIVE

The first study to predict peritrochanteric fractures by the use of T scores amongst the Indian population was performed. This study aimed to assess the risk of fracture around the hip in peri-menopausal and postmenopausal women, and in men over the age of 35 years using dual energy X-ray absorptiometry, and to analyse whether the result, i.e. the T score, can predict an impending hip fracture.

METHODS

T scores of the unaffected hip in 30 patients with peritrochanteric fractures were determined, and matched pair analysis was done using a control group without fracture. All patients were from a single centre and were evaluated using the same scanner.

RESULTS

The mean T score of the 30 patients in the fracture group was -3.34 (range, -1.2 to -5.1; standard deviation [SD], 1.032), compared with the mean T score of the 30 control subjects which was -2.41 (range, 0.6 to -5.0; SD, 1.378). T scores of patients from the fracture group were significantly lower than those in the control group.

CONCLUSION

We infer that T scores are the best predictors for fracture risk. A score of -2.5 or lower effectively defines patients at risk and is useful for predicting fracture risk in the Indian population. In patients with osteoporosis, whether a fall precedes the fracture or the fracture precedes a fall may not be an issue of debate, but can serve as a basis for prevention of additional fractures by instituting appropriate measures in patients at risk.

The use of a dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture

A study was designed to examine the outcomes of patients with closed comminuted subtrochanteric femoral fractures fixed with a dynamic condylar screw (DCS) and using biological (indirect) reduction techniques at a tertiary referral centre.Thirty-one consecutive patients with a mean age of 32.6 years, who sustained subtrochanteric femoral fractures, were treated with this method. Twenty-seven cases (87.2%) sustained these fractures either from traffic crashes or falls from height and the remaining four had a simple fall. Average follow-up was 3 years (range 14-65 months). Patients were assessed clinically and radiographically with regards to fracture classification, operating time, blood loss, time of union, malunion and other complications. Union was achieved in all cases (100%), with full-weight bearing after an average of 4.9 months. The average operating time was 2h and blood loss averaged 430 ml. There was only one case of superficial infection, which settled with local debridement and antibiotics. Malunion was seen in 2 cases out of 31 (6.4%) without the need for further surgery. In conclusion, use of biological (indirect) reduction techniques instead of anatomic, open reduction has proven to be successful, especially in comminuted subtrochanteric fractures. The early appearance of callus avoids the need for primary cancellous bone grafting, emphasising the importance of preserving biology of the fracture fragments.

Multiple joint replacement in chronically neglected polyarthritic patients: Two case reports

Multiple joint replacement is a viable option for rehabilitation of young polyarthritic patients with unsalvageable joints. Young polyarthritic patients in this part of the world suffer from chronic neglect because of ignorance, apathy and low socio-economic status. During the period of chronic neglect, these patients acquire extreme deformities of various joints either due to active disease (ankylosing spondylitis, rheumatoid arthritis) or irreversible changes in the joint configuration like ankylosis and soft-tissue contracture. Associated spine and thoracic cage affection create problems for anaesthesia and peri-operative positioning. We report 2 cases of multiple joint replacements for young polyarthritic patients who were bedridden for 6 to 11 years. Surgeries were performed in a phased manner and after extensive rehabilitation both patients were able to walk unaided. Various problems and difficulties encountered have been addressed so as to serve as a guide to surgeons who may have to deal with such unusual situations of chronic neglect. We also report a modified exposure technique without trochanteric osteotomy for total hip replacement, which is valuable in extreme external rotation ankylosis.

Anthropometric measurements to design total knee prostheses for the Indian population

An anthropometric computed tomography scan study was undertaken to design femoral components in 86 knees (47 osteoarthritic Indians-21 men, 26 women) who matched standards suggested by the Indian Council of Medical Research, 1990. Patients were classified into 3 random groups based on anteroposterior diameter (<55 mm, 55-59 mm, >59 mm). Most Indian men (86.8%) could have the femoral component satisfactorily replaced by available designs. A statistically significant number of women (60.4%, P < .001) had femoral anteroposterior diameters smaller than the smallest available (55 mm) femoral component. Splaying in mediolateral dimension (> 10 mm) in a given anteroposterior size was noted in all 3 groups. This pilot study representative of the Indian population can be used to manufacture prosthetic inventories suitable for most of the Asian-Pacific population having smaller anthropometric measurements than Western populations.

Irreducible lateral dislocation of the elbow

A rare case of an irreducible post-traumatic lateral dislocation of elbow is presented. The mechanism of injury was fall on a flexed elbow with trauma on its medial aspect resulting in pronation of the forearm. At open reduction, the brachialis muscle was in the form of a tight band which prevented reduction. The ulnar nerve was entrapped in the joint.

Results of Austin Moore replacement

Forty cases of Austin Moore Replacement done for transcervical fractures of the femur in patients were reviewed after a period of 12 to 48 months postoperatively (mean 26 mth). 30 cases (75%) had mild to severe pain of non-infective origin, starting as early as 6 months postoperatively. This was irrespective of the make, size or position (varus/valgus) of the prosthesis. Though the Aufranc and Sweet clinical scoring was satisfactory in 65% cases, radiological evidence of complications like sinking, protrusion, etc. were seen in majority of the cases. Calcar resorption was seen in 34 cases (85%) as early as 4 months postoperatively. Results of THR and bipolar replacement done for transcervical fractures in recent literature show 85% pain-free cases at 5 years. We feel that Austin Moore Replacement should be reserved for patients more than 65 years of age and those who are less active or debilitated because of other factors, because of increased acetabular wear with time in the younger individual. This is corroborated by unsatisfactory results in patients less than 65 years of age (p < 0.05).

Left ventricular aneurysm: angiographic determinants

To determine antiographic factors involved in left ventricular aneurysm formation after myocardial infarction, 50 patients with a first anterior wall myocardial infarction who underwent cardiac catheterisation within 6 months of infarction were evaluated. Extent of coronary artery disease and status of collateral circulation were studied in detail. Thirty patients had aneurysm in apical region while 20 patients showed aneurysm in anteroapical region. Coronary angiography revealed single-vessel disease in 17 patients, double-vessel disease in 17 patients and triple-vessel disease in 15 patients while in one patient coronary angiogram was normal. Fortynine patients showed significant involvement of left anterior descending artery which was poorly collateralised. Left anterior descending artery disease in association with inherent poor collateral blood supply may predispose for aneurysm formation after anterior wall myocardial infarction.