BACKGROUND:More than 75,000 total hip replacements were performed in England and Wales in 2014, and this figure is predicted to increase. Trends in mortality and complications following total hip ...replacement from 2005 to 2014 were evaluated to quantify risk and to identify “at-risk” groups to better inform recommendations for patient care.
METHODS:Our primary analysis estimated 90-day inpatient mortality following total hip replacement using Hospital Episode Statistics data from 2005 to 2014. Secondary analyses explored 30-day rates of lower respiratory tract infection, renal failure, myocardial infarction, pulmonary embolism, deep-vein thrombosis, cerebrovascular accident, and Clostridium difficile. Hierarchical logistic regression was used to estimate population averages, adjusting for time and prognostic covariates.
RESULTS:From January 2005 to July 2014, a total of 540,623 total hip replacements were reported. The 90-day mortality rate dropped steadily, from 0.60% in 2005 to 0.15% in 2014. Reported postoperative complications (with the exception of lower respiratory tract infection and renal failure) reduced year-on-year, despite a steady rise in the average Charlson Comorbidity Index score. The 30-day rate of lower respiratory tract infection and renal failure increased from 0.54% to 0.84% and 0.21% to 1.09%, respectively. The risk of mortality was significantly higher for those who developed a lower respiratory tract infection (odds ratio OR = 42.3) or renal failure (OR = 36.5) than for those who developed pulmonary embolism (OR = 10.9) or deep-vein thrombosis (OR = 2.6).
CONCLUSIONS:Despite a population with increasing levels of comorbidity, indicators of quality of care improved from 2005 to 2014, with the exception of the rates of lower respiratory tract infection and renal failure. Postoperative care should focus on reducing the risk of lower respiratory tract infection and renal failure, both of which increased and were strongly associated with mortality. Moreover, they appeared to occur in identifiable high-risk groups; modifications to routine care should be considered for these patients.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Prosthetic joint infection (PJI) following total hip replacement (THR) surgery is a serious complication that negatively impacts patients' lives and is financially burdensome for healthcare ...providers. As the number of THRs increases, so does this financial burden. This research estimates the economic burden with respect to inpatient and day case hospital admissions for patients receiving revision surgery for PJI following primary THR.
In this matched cohort study, the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was used to identify patients. Patients revised for PJI with a one- or two-stage revision following THR and patients not revised for PJI were matched on several characteristics using exact and radius matching. Hospital inpatient and day case healthcare records from the English Hospital Episode Statistics database were obtained for 5 years following the identified patient's primary THR. UK national unit costs were applied to hospital admissions and the 5-year total cost was estimated. A two-part model (Probit and generalised linear model) was employed to estimate the incremental difference in costs between those revised and not revised for PJI.
Between 2006 and 2009, 1914 revisions for PJI were identified in the NJR. The matching resulted in 422 patients revised for PJI and 1923 matches not revised for PJI who were included in the analysis. The average cost of inpatient and day case admissions in the 5 years following primary THR was approximately £42,000 for patients revised for PJI and £8000 for patients not revised for PJI. The difference in costs over the 5 years was £33,452 (95% CI £30,828 to £36,077; p < 0.00).
In the 5 years following primary THR, patients who develop PJI and have revision surgery cost approximately £33,000 (over 5-fold) more than patients not revised for PJI based on their hospital inpatient and day case admissions alone. The total burden of PJI is likely to be much higher when also considering outpatient, primary and community care costs. This highlights the need to find both ways to reduce the incidence of PJI following THR and cost-effective treatment strategies if PJI occurs.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose Our study aimed to identify the complications of hip arthroscopies with particular emphasis on the 30-day readmission rate; 90-day deep vein thrombosis (DVT) and pulmonary embolism (PE) rate ...and mortality rate; revision hip arthroscopy rate; and in particular, survivorship with conversion to total hip replacement (THR) as the endpoint. Methods The records of patients undergoing hip arthroscopy were extracted from the administrative hospital admissions database covering all admissions to the National Health Service hospitals in England using ICD-10 ( International Statistical Classification of Diseases and Related Health Problems, 10th Revision ) and OPCS-4 (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, fourth revision) codes. Results A total of 6,395 hip arthroscopies were included in the study period. The 30-day readmission rate was 0.5%; both the 90-day DVT rate and PE rate were 0.08%; and the 90-day mortality rate was 0.02%. THR was performed in 680 patients (10.6%) at a mean of 1.4 years after the index operation, and 286 patients (4.5%) underwent revision hip arthroscopy at a mean of 1.7 years. Kaplan-Meier survival analysis showed an 8-year survival rate of 82.6% (95% confidence interval CI, 80.9% to 84.2%), whereas Cox proportional hazard analysis adjusting for age, gender, and Charlson comorbidity score showed an 8-year survival rate of 86%. Female patients had a 1.68 times (95% CI, 1.41 to 2.01) higher risk of conversion to THR than male patients, and patients aged 50 years or older had a 4.65 (95% CI, 3.93 to 5.49) times higher risk of requiring hip replacement than patients younger than 50 years. Conclusions In this large series of 6,395 hip arthroscopies looking at the national data from the English National Health Service, our null hypothesis has been supported, and we have determined that the rate of short-term complications, in particular the risk of DVT and PE after this operation, is low. Higher age and female gender are significant predictors of conversion to THR, with Cox proportional hazard analyses showing a survivorship rate of 86% at 8 years after adjustment for confounding variables. Level of Evidence Level IV, therapeutic case series.
Abstract Influence of BMI upon patient outcomes and complications following THA was examined across a national cohort of patients. Outcomes were compared by BMI groups (19.0–29.9 kg/m2 reference, ...30.0–34.9 kg/m2 obese class I, 35.0 kg/m2 + obese class II/III), adjusted for case-mix differences. Obese class I patients had a significantly smaller improvement in OHS (18.9 versus 20.5, P < 0.001) and a greater risk of wound complications (odds ratio OR = 1.57, P = 0.006). For obese class II/III patients, there were significantly smaller improvements in OHS and EQ-5D index ( P < 0.001), and greater risk of wound complications ( P = 0.006), readmission ( P = 0.001) and reoperation ( P = 0.003). Large improvements in patient outcomes were seen irrespective of BMI, although improvements were marginally smaller and complication rates higher in obese patients.
Hip fracture is the most common injury requiring treatment in hospital. Controversy exists regarding the use of antibiotic loaded bone cement in hip fractures treated with hemiarthroplasty. We aimed ...to compare the rate of deep surgical site infection in patients receiving high-dose dual-antibiotic loaded cement versus standard care single-antibiotic loaded cement.
We included people aged 60 years and older with a hip fracture attending 26 UK hospitals in this randomised superiority trial. Participants undergoing cemented hemiarthroplasty were randomly allocated in a 1:1 ratio to either a standard care single-antibiotic loaded cement or high-dose dual-antibiotic loaded cement. Participants and outcome assessors were masked to the treatment allocation. The primary outcome was deep surgical site infection at 90 days post-randomisation as defined by the US Centers for Disease Control and Prevention in an as-randomised population of consenting participants with available data at 120 days. Secondary outcomes were quality of life, mortality, antibiotic use, mobility, and residential status at day 120. The trial is registered with ISRCTN15606075.
Between Aug 17, 2018, and Aug 5, 2021, 4936 participants were randomly assigned to either standard care single-antibiotic loaded cement (2453 participants) or high-dose dual-antibiotic loaded cement (2483 participants). 38 (1·7%) of 2183 participants with follow-up data in the single-antibiotic loaded cement group had a deep surgical site infection by 90 days post-randomisation, as did 27 (1·2%) of 2214 participants in the high-dose dual-antibiotic loaded cement group (adjusted odds ratio 1·43; 95% CI 0·87–2·35; p=0·16).
In this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip.
Heraeus Medical. Supported by the UK National Institute for Health and Care Research Oxford Biomedical Research Centre.
Background and purpose Enhanced Recovery (ER) is a well-established multidisciplinary strategy in lower limb arthroplasty and was introduced in our department in May 2008. This retrospective study ...reviews short-term outcomes in a consecutive unselected series of 3,000 procedures (the "ER" group), and compares them to a numerically comparable cohort that had been operated on previously using a traditional protocol (the "Trad" group).
Methods Prospectively collected data on surgical endpoints (length of stay (LOS), return to theater (RTT), re-admission, and 30- and 90-day mortality) and medical complications (stroke, gastrointestinal bleeding, myocardial infarction, and pneumonia within 30 days; deep vein thrombosis and pulmonary embolism within 60 days) were compared.
Results ER included 1,256 THR patients and 1,744 TKR patients (1,369 THRs and 1,631 TKRs in Trad). The median LOS in the ER group was reduced (3 days vs. 6 days; p = 0.01). Blood transfusion rate was also reduced (7.6% vs. 23%; p < 0.001), as was RTT rate (p = 0.05). The 30-day incidence of myocardial infarction declined (0.4% vs. 0.9%; p = 0.03) while that of stroke, gastrointestinal bleeding, pneumonia, deep vein thrombosis, and pulmonary embolism was not statistically significantly different. Mortality at 30 days and at 90 days was 0.1% and 0.5%, respectively, as compared to 0.5% and 0.8% using the traditional protocol (p = 0.03 and p = 0.1, respectively).
Interpretation This is the largest study of ER arthroplasty, and provides safety data on a consecutive unselected series. The program has achieved a statistically significant reduction in LOS and in cardiac ischemic events for our patients, with a near-significant decrease in return to theater and in mortality rates.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
BACKGROUND:There is evidence to support the use of highly cross-linked polyethylene (HXLPE) in patients undergoing total hip arthroplasty. However, the benefits for those undergoing total knee ...arthroplasty are uncertain, with conflicting reports based on previous cohort analyses. The purpose of the present study was to compare the revision rates following primary total knee arthroplasty with use of HXLPE as compared with conventional polyethylene (CPE) using data from the National Joint Registry (NJR) for England, Wales and Northern Ireland.
METHODS:We performed a retrospective analysis of primary total knee arthroplasties recorded in the NJR from 2003 to 2014. Cobalt-chromium (CoCr)-CPE and CoCr-HXLPE bearing surfaces were compared using all-cause revision, aseptic revision, and septic revision as end points. Survival analyses were conducted using rates per 100 years observed, Kaplan-Meier survival estimates, and Cox regression hazard ratios (HRs) adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), lead surgeon grade, and implant constraint. Secondary analyses compared the most commonly used HXLPEs (Zimmer Prolong, DePuy XLK, and Stryker X3) against CPE for the 3 most common total knee arthroplasty systems (NexGen, PFC Sigma, and Triathlon).
RESULTS:In the present study of 550,658 total knee arthroplasties, the unadjusted aseptic revision rates were significantly lower following procedures performed with CPE (n = 513,744) as compared with those performed with HXLPE total knee replacements (n = 36,914) (0.29 95% confidence interval (CI), 0.28 to 0.30 compared to 0.38 95% CI, 0.35 to 0.42, p < 0.01). The 10-year HR associated with CPE was 0.4 (95% CI, 0.1 to 0.8, p = 0.03). There were no significant differences between the adjusted revision rates of HXPLE compared with CPE in individual analyses of the most common total knee arthroplasty systems. However, for the subset of patients who were both <60 years of age and had a BMI of >35 kg/m, the “second-generation” Stryker X3 HXLPE demonstrated significantly better survival than its respective CPE, with CPE having an HR of 2.6 (95% CI, 1.2 to 5.9) (p = 0.02).
CONCLUSIONS:Alternative bearings are marketed as having improved wear properties over traditional CoCr-CPE. This registry-based analysis demonstrated no overall survival benefit of HXLPE after a maximum duration of follow-up of 12 years. Because of their increased cost, the routine use of HXLPE bearings may not be justified. However, they may have a role in specific “higher demand” groups such as patients <60 years of age and/or those with a BMI of >35 kg/m.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete list of levels of evidence.
Background and purpose Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden ...of joint replacement by reducing length of stay, but also helps in reduction of early complications.
Patients and methods We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications.
Results There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction
(0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8).
Interpretation This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
BACKGROUND:Studies have suggested that the anterolateral approach is preferable to the posterior approach when performing total hip arthroplasty (THA) for a displaced intracapsular hip fracture, ...because of a perceived reduced risk of reoperations and dislocations. However, this suggestion comes from small studies with short follow-up. We determined whether surgical approach in THAs performed for hip fracture affects revision-free hip survival, patient survival, and intraoperative complications.
METHODS:We retrospectively analyzed all stemmed primary THAs for hip fracture that were recorded in the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man that were performed between 2003 and 2015. The 2 surgical approach groups, posterior and anterolateral, were matched for patient and surgical confounding factors using propensity scores, with outcomes compared using regression modeling (with regression model ratios of <1 representing a reduced risk of the specified outcome in the posterior group). Outcomes were 5-year hip survival free from revision (all-cause revision, revision for dislocation and/or subluxation, and revision for periprosthetic fracture), patient survival (30 days, 1 year, and 5 years postoperatively), and intraoperative complications.
RESULTS:After matching, 14,536 THAs (7,268 per group) were studied. Five-year cumulative revision-free survival rates were similar (posterior group, 97.3%, and anterolateral group, 97.4%; subhazard ratio SHR, 1.15 95% confidence interval (CI), 0.93 to 1.42). Five-year survival rates free from revision for dislocation (SHR, 1.28 95% CI, 0.89 to 1.84) and for periprosthetic fracture (SHR, 1.03 95% CI, 0.68 to 1.56) were also comparable between the 2 approach groups. Thirty-day patient survival was significantly higher following a posterior approach (99.5% compared with 98.8%; hazard ratio HR, 0.44 95% CI, 0.30 to 0.64), which persisted at 1 year (HR, 0.73 95% CI, 0.64 to 0.84) and 5 years (HR, 0.87 95% CI, 0.81 to 0.94) postoperatively. The posterior approach was associated with a lower risk of intraoperative complications (odds ratio OR, 0.59 95% CI, 0.45 to 0.78).
CONCLUSIONS:In THA for hip fracture, the posterior approach was associated with a similar risk of revision and a lower risk of both patient mortality and intraoperative complications compared with the anterolateral approach. We propose that the posterior approach is as safe as the anterolateral approach when performing THA for hip fracture and that either approach may be used according to surgeon preference.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Intra-articular injection is effective for osteoarthritis, but the best single injection strategy is not known, nor are there established predictors of response. The objectives of this study were to ...assess and predict response to a single ultrasound-guided injection in moderate to severe hip osteoarthritis.
77 hip osteoarthritis patients entered a prospective, randomised controlled trial, randomised to one of four groups: standard care (no injection); normal saline; non-animal stabilised hyaluronic acid (durolane) or methylprednisolone acetate (depomedrone).
Numerical rating scale (NRS 0-10) 'worst pain', Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain/function. Potential predictors of response (including radiographic severity, ultrasound synovitis and baseline symptom severity) were examined using univariate logistic regression analysis and Fisher's exact test.
NRS pain, WOMAC pain and function improved significantly for the steroid arm alone. Effect sizes at week 1 were striking: NRS pain 1.5, WOMAC pain 1.9 and WOMAC function 1.3. Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society responder criteria identified 22 responders (intention-to-treat): steroid 14 (74%; number needed to treat, two); saline, four (21%); durolane, two (11%); and no injection, two (10%; χ(2) test between groups, p<0.001). Corticosteroid arm response was maintained over 8 weeks (summary measures analysis of variance, p<0.002 for NRS pain). Synovitis was a significant predictor of response at weeks 4 and 8 (p<0.05, Fisher's exact test; week 4 OR 16.7, 95% CI 1.4 to 204).
Ultrasound-guided corticosteroid injections are highly efficacious; furthermore synovitis on ultrasound is a biomarker of response to injection.
PDF
