The ability to identify which patients are at a greater risk of early revision knee arthroplasty has important practical and resource implications. Many international arthroplasty registries ...administer patient-reported outcome measures (PROMs) to provide a holistic assessment of pain, function, and quality of life. However, few PROM scores have been evaluated as potential indicators of early revision knee arthroplasty, and earlier studies have largely focused on knee-specific measures.
This national registry-based study asked: (1) Which 6-month postoperative knee-specific and generic PROM scores are associated with early revision knee arthroplasty (defined as revision surgery performed 6 to 24 months after the primary procedure)? (2) Is a clinically important improvement in PROM scores (based on thresholds for the minimal important change) after primary knee arthroplasty associated with a lower risk of early revision?
Preoperative and 6-month postoperative PROM scores for patients undergoing primary knee arthroplasty were sourced from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and Arthroplasty Clinical Outcomes Registry National. Between January 2013 and December 2020, PROM data were available for 19,402 primary total knee arthroplasties; these data were linked to AOANJRR data on revision knee arthroplasty. Of these, 3448 procedures were excluded because they did not have 6-month PROM data, they had not reached the 6-month postoperative point, they had died before 24 months, or they had received revision knee arthroplasty before the 6-month PROMs assessment. After these exclusions, data were analyzed for 15,954 primary knee arthroplasties. Associations between knee-specific (knee pain, Oxford Knee Score, and 12-item Knee injury and Osteoarthritis Outcome Score KOOS-12) or generic PROM scores (5-level EuroQol quality of life instrument EQ-5D, EQ VAS, perceived change, and satisfaction) and revision surgery were explored using t-tests, chi-square tests, and regression models. Ninety-four revision procedures were performed at 6 to 24 months, most commonly for infection (39% 37 procedures). The early revision group was younger than the unrevised group (mean age 64 years versus 68 years) and a between-group difference in American Society of Anesthesiologists (ASA) grade was noted. Apart from a small difference in preoperative low back pain for the early revision group (mean low back pain VAS 4.2 points for the early revision group versus 3.3 points for the unrevised group), there were no between-group differences in preoperative knee-specific or generic PROM scores on univariate analysis. As the inclusion of ASA grade or low back pain score did not alter the model results, the final multivariable model included only the most clinically plausible confounders (age and gender) as covariates. Multivariable models (adjusting for age and gender) were also used to examine the association between a clinically important improvement in PROM scores (based on published thresholds for minimal important change) and the likelihood of early revision.
After adjusting for age and gender, poor postoperative knee pain, Oxford, KOOS-12, EQ-5D, and EQ VAS scores were all associated with early revision. A one-unit increase (worsening) in knee pain at 6 months was associated with a 31% increase in the likelihood of revision (RR 1.31 95% confidence interval (CI) 1.19 to 1.43; p < 0.001). Reflecting the reversed scoring direction, a one-unit increase (improvement) in Oxford or KOOS-12 score was associated with a 9% and 5% reduction in revision risk, respectively (RR for Oxford: 0.91 95% CI 0.90 to 0.93; p < 0.001; RR for KOOS-12 summary: 0.95 95% CI 0.94 to 0.97; p < 0.001). Patient dissatisfaction (RR 6.8 95% CI 3.7 to 12.3) and patient-perceived worsening (RR 11.7 95% CI 7.4 to 18.5) at 6 months were also associated with an increased likelihood of early revision. After adjusting for age and gender, patients who did not achieve a clinically important improvement in PROM scores had a higher risk of early revision (RR 2.9 for the knee pain VAS, RR 4.2 for the Oxford Knee Score, RR 6.3 to 8.6 for KOOS-12, and RR 2.3 for EQ-5D) compared with those who did (reference group).
Knee-specific and generic PROM scores offer an efficient approach to identifying patients at greater risk of early revision surgery, using either the 6-month score or the magnitude of improvement. These data indicate that surgeons can use single- and multi-item measures to detect a patient-perceived unsuccessful surgical outcome at 6 months after primary knee arthroplasty. Surgeons should be alert to poor PROM scores at 6 months or small improvements in scores (for example, less than 2 points for knee pain VAS or less than 10.5 points for Oxford Knee Score), which signal a need for direct patient follow-up or expedited clinical review.
Level III, therapeutic study.
Tranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA); however, the most appropriate route of administration is still debated. This study was conducted to compare the 2 most ...commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA).
This study was conducted as a double-blind, randomized, noninferiority trial and included patients undergoing primary unilateral TKA. Patients were randomized to receive IV or IA TXA and compared for postoperative fall in hemoglobin (Hb) on day 1 (primary outcome) and day 2, and blood transfusion rates, length of stay, and complications.
Of the 183 patients recruited, 168 were included and supplied complete data. The between-group difference in mean Hb fall at day 1 was 0.08 g/dL with the Hb fall higher in the IA group. The 95% confidence interval was −0.18 to 0.34 which did not reach the noninferiority margin of 0.5 g/dL. No significant difference was seen in the secondary outcomes.
IA TXA is noninferior to IV TXA in terms of fall in Hb on the first postoperative day. Due to the potential for reduced serum levels and easier administration (single dose), this trial supports the use of IA TXA for primary TKA.
Background
The collection of patient-reported outcome measures (PROMs) following arthroplasty is common. PROMs data collection programs seek to maximise completeness in order to minimise selection ...bias and optimise representativeness of the sample attained. We aimed to determine if patient factors influence variation in PROMs program completeness between-hospitals.
Methods
Using data from a national arthroplasty registry PROMs program, we tested for associations between patient characteristics (age, sex, body mass index BMI and American Society of Anaesthesiologists ASA class) and both potential completeness (registration completeness: the proportion of arthroplasty patients that were registered in the PROMs electronic system) and actual completeness (response completeness: the proportion of arthroplasty patients who provided PROMs data) using linear regression.
Results
When using all elective primary total hip, knee or shoulder arthroplasty procedures (N = 31,801) from 43 hospitals as the denominator, overall registration completeness was 52%, varying from 5 to 87% between hospitals. Overall pre-operative response completeness was 46%, varying from 5 to 82% between hospitals. There were no significant associations between hospital-level registration completeness or response completeness and age, sex, BMI or ASA score.
Conclusion
Completeness rates of a PROMs program in arthroplasty varied widely between hospitals but in the absence of a relationship between measured patient factors and completeness rates, the observed variation likely relates to local site factors such as access to patients, local resources and clinician engagement with the program. Efforts to improve the rates of completeness of arthroplasty PROMs programs at individual hospitals may not improve the representativeness of the sample.
Plain English summary
Hospitals vary in how completely they include and follow up patients when measuring patient-reported health. It is important to know if the completeness of inclusion and follow up by hospitals is affected by patient characteristics. This study addresses that problem by using data from a national patient outcome survey involving over 30,000 patients from 43 hospitals to look at the correlation between certain patient characteristics (like age, sex, obesity and general health) and the rates of inclusion and follow up for each hospital.
Rates of inclusion (registering patients in the program) and follow up rates varied widely between hospitals (from 5 to 87%). The rates of inclusion and follow up were not correlated with patient age, sex, body mass index or their general health. These findings suggest that the variation between hospitals in the rates of inclusion of joint replacement patients in health surveys are not due to differences in patient characteristics. The differences may be due to local hospital factors, such as resources and clinician engagement.
Purpose.
To determine whether intra-articular tranexamic acid (TXA) use after total knee arthroplasty (TKA) results in decreased postoperative blood transfusion and length of hospital stay.
Methods.
...Medical records of 1981 patients (mean age, 69.2 years) who underwent primary TKA with (n=1006) or without (n=975) TXA use by any of 4 knee arthroplasty surgeons were reviewed. TXA (3000 mg/30ml) was administered via an epidural catheter into the knee joint after wound closure. Postoperative blood transfusion was given to patients with haemoglobin (Hb) level <80 g/dl on days 1 and 2 or with symptoms of acute anaemia.
Results.
Intra-articular TXA use after TKA resulted in a lower blood transfusion rate (4.5% 45/1006 vs. 14.8% 144/975, p<0.0001), fewer units of blood transfused (86 vs. 313 units, p<0.0001), fewer units of blood transfused per 100 patients (8.5 vs. 32.1, p<0.0001), and shorter length of hospital stay (4.7±2.3 vs. 5.3±2.7 days, p<0.0001). Total cost savings with respect to the reduction in blood transfusion was AU$143.68 per patient. When the change in length of hospital stay and TXA costs were included, the overall saving was AU$631.36 per patient.
Conclusion.
Intra-articular TXA use can reduce costs as a result of decreased blood transfusion rate and length of hospital stay in patients undergoing TKA.
The initial biomechanical properties of semitendinosus and patellar tendon autografts and their fixation strengths were investigated. Twenty fresh cadaveric knees from donors under 42 years of age ...were used in the study. After removing all soft tissues other than the anterior cruciate ligament, we determined the ultimate tensile strength (2195 +/- 427 N) and stiffness (306 +/- 80 N/mm) of the anterior cruciate ligament in nine knees. In six knees, anterior cruciate ligaments were reconstructed using an autologous patellar tendon graft with proximal and distal interference fit screws; this resulted in an ultimate tensile strength of 416 +/- 66 N. Five knees were reconstructed with quadruple-stranded (double-looped) semitendinosus tendons fixed proximally by a titanium button and braided tape and distally by tibial post screw. This resulted in an ultimate tensile strength of 612 +/- 73 N, which was significantly higher than the strength in the patellar tendon group. Graft stiffness did not differ between the groups and was 47 +/- 19 N/mm (N = 11). This study demonstrates that the reconstructed knees had only 20% to 30% of the ultimate tensile strength of the normal anterior cruciate ligament. In summary, the semitendinosus reconstruction using a button for proximal fixation is, at the time of surgery, approximately 50% stronger than patellar tendon reconstructions with similar stiffness.
Unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) and high tibial osteotomy (HTO) may all be used to treat unicompartmental osteoarthritis, but they are often used for different ...patient groups. However, there is considerable overlap in indications for all three options. The aim of this review was to assess the safety and efficacy of UKA compared with TKA and HTO in unicompartmental osteoarthritis. Studies that compared UKA with either TKA or HTO were identified and included for review. For knee function and postoperative pain, UKA appeared similar to TKA and HTO at 5 years follow up. Range of motion was better in UKA compared with TKA. Complication rates after UKA and TKA appeared similar, although deep vein thrombosis was reported more often after TKA. There were more complications after HTO than UKA. Survival of UKA prostheses was approximately 85–95%, compared with at least 90% for TKA at 10 years follow up. Survivorship for HTO appeared to be less than 85%. It was not clear whether there were more revisions after UKA than TKA, but there appeared to be fewer revisions in UKA compared with HTO. UKA is considered at least as safe as TKA and HTO. For function, UKA appears to be at least as efficacious as TKA and HTO. The survival of UKA compared with TKA and HTO cannot be determined based on the available evidence.
Abstract Background Tranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA), however the most appropriate route of administration is still debated. This study was conducted to ...compare the two most commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA). Methods This study was conducted as a double blind randomized non-inferiority trial and included patients undergoing primary unilateral TKA. Patients were randomized to receive IV or IA TXA and compared for post-operative fall in hemoglobin (Hb) on day one (primary outcome) and day two, and blood transfusion rates, length of stay and complications. Results Of the 183 patients recruited, 168 were included and supplied complete data. The between group difference in mean Hb fall at day 1 was 0.08g/dL with the Hb fall higher in the IA group. The 95% confidence interval was -0.18 to 0.34 which did not reach the non-inferiority margin of 0.5g/dL. No significant difference was seen in the secondary outcomes. Conclusions Intra-articular TXA is non-inferior to IV TXA in terms of fall in Hb on the first post-operative day. Due to the potential for reduced serum levels and easier administration (single dose), this trial supports the use of IA TXA for primary TKA.
Objectives:
Tranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA) to reduce blood loss, however the most appropriate route of administration is still debated. This study was ...conducted to compare the two most commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA).
Methods:
This study was conducted as a non-inferiority, double blinded randomized trial to compare IA TXA with IV TXA in terms of efficacy in reducing blood loss as measured by post-operative Hb drop and transfusion rates. We hypothesized that IA TXA is not inferior to IV TXA in reducing blood loss and transfusion requirements.
Results:
One hundred and sixty eight patients were analysed. Mean day 1 and day 2 post-operative Hb values for both the groups were statistically similar (p=0.88, p=0.95 respectively). Also, no statistical difference was seen on comparison of change in Hb between pre-operative and day 1 or day 2 values (p=0.55, p=0.58 respectively). There were no transfusions given in either group.
Conclusion:
Intra-articular TXA is non-inferior to IV TXA in terms of fall in Hb and blood transfusion requirements. This trial further establishes and supports the use of IA TXA for primary TKA.
Objectives:Tranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA) to reduce blood loss, however the most appropriate route of administration is still debated. This study was ...conducted to compare the two most commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA).Methods:This study was conducted as a non-inferiority, double blinded randomized trial to compare IA TXA with IV TXA in terms of efficacy in reducing blood loss as measured by post-operative Hb drop and transfusion rates. We hypothesized that IA TXA is not inferior to IV TXA in reducing blood loss and transfusion requirements.Results:One hundred and sixty eight patients were analysed. Mean day 1 and day 2 post-operative Hb values for both the groups were statistically similar (p=0.88, p=0.95 respectively). Also, no statistical difference was seen on comparison of change in Hb between pre-operative and day 1 or day 2 values (p=0.55, p=0.58 respectively). There were no transfusions given in either group.Conclusion:Intra-articular TXA is non-inferior to IV TXA in terms of fall in Hb and blood transfusion requirements. This trial further establishes and supports the use of IA TXA for primary TKA.
CLINICAL REVIEW Tabatha Griffin; Neville Rowden; David Morgan ...
ANZ journal of surgery,
04/2007, Volume:
77, Issue:
4
Journal Article
Peer reviewed
Unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) and high tibial osteotomy (HTO) may all be used to treat unicompartmental osteoarthritis, but they are often used for different ...patient groups. However, there is considerable overlap in indications for all three options. The aim of this review was to assess the safety and efficacy of UKA compared with TKA and HTO in unicompartmental osteoarthritis. Studies that compared UKA with either TKA or HTO were identified and included for review. For knee function and postoperative pain, UKA appeared similar to TKA and HTO at 5 years follow up. Range of motion was better in UKA compared with TKA. Complication rates after UKA and TKA appeared similar, although deep vein thrombosis was reported more often after TKA. There were more complications after HTO than UKA. Survival of UKA prostheses was approximately 85-95%, compared with at least 90% for TKA at 10 years follow up. Survivorship for HTO appeared to be less than 85%. It was not clear whether there were more revisions after UKA than TKA, but there appeared to be fewer revisions in UKA compared with HTO. UKA is considered at least as safe as TKA and HTO. For function, UKA appears to be at least as efficacious as TKA and HTO. The survival of UKA compared with TKA and HTO cannot be determined based on the available evidence. PUBLICATION ABSTRACT
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