Epidemiology And Treatment Of Pain Associated With Osteoarthritis Of The Knee In Germany: A Retrospective Health Claims Data Analysis

Purpose: Osteoarthritis of the knee (knee OA) is the most prevalent form of OA, frequently leading to significant pain and an overall reduction in quality of life. The available options for managing pain, associated with knee OA, are well documented. They include various oral analgesic medications (for example, NASIDs and opioids), intraarticular agents, notably, hyaluronic acid and corticosteroids, and where pharmacological and lifestyle options have been exhausted, orthopedic surgery, including total knee replacement (TKR). The treatment option(s) a patient may receive, in which order and at what time point, post-diagnosis may vary significantly between healthcare centers. The current study focuses specifically on knee OA in Germany, aiming to determine the epidemiology, patient characteristics and treatment schemes for the management of pain associated with knee OA. Method(s): A non-interventional, retrospective health claims data analysis was performed with an anonymized, age- and sex-representative sample of the Institute for Applied Health Research Berlin GmbH (InGef) database. The database that was used for this study includes approximately 4.8 million persons from approx. 60 statutory health insurances (SHI). Patients >=18 years of age were analyzed cross-sectionally for each year 2015-2020. Using ICD-10 and ATC codes, newly diagnosed patients in 2015 were also analyzed longitudinally until end of 2020. Result(s): The average period prevalence of knee OA was 7.34%, with a slight increase during the years 2015-2020. Incidence ranged from 1.71% of patients in 2015 to 1.46% of patients in 2020. Females and patients aged >=66 years had both a higher prevalence and incidence proportion compared to males and younger persons. Approximately 62% of newly diagnosed patients in 2015 received medical treatment during follow-up, most of whom were prescribed non-opioid analgesics;WHO I category (96.84%), followed by WHO II (2.45%) and WHO III (0.71%), as first line treatment. This analysis could not account for the use of any over the counter medications, or medicines prescribed in hospital, prior to, or after diagnosis. As many as 16.58% of newly diagnosed patients had surgery within 5 years. Knee replacement was the most common type of surgery with rising prevalence. The number of patients in whom surgery was performed decreased slightly from 5,38% to 4,03% during the study years considered (Figure 1);the decrease in 2020 may, in-part, be a reflection of the COVID-19 pandemic and the knock-on impact on healthcare systems. Of the 8,318 surgical patients, 2,101 patients (25.26%) had no record of having received any prescription pharmacological treatment prior to first surgery. The median time from first diagnosis until surgery in newly diagnosed patients was 346 days for any surgery, and 564 days for knee replacement. [Formula presented] Conclusion(s): With a stable incidence and a growing population, the number of patients with knee OA in Germany is slowly rising. In parallel, there is an slight decrease in total knee surgeries occurring each year with an increasing proportion of TKRs. Time until first surgery, in general, and TKR in newly diagnosed patients is relatively short, compared to other countries, with some patients having no record of having received any prescription medication prior to first surgery. Other treatment options such as opioids and intraarticular agents, appear to play a relatively minor role, in newly diagnosed patients, in current practice in Germany.Copyright © 2023

Total knee arthroplasty in the outpatient vs inpatient settings: impact of site of care on early postoperative economic and clinical outcomes.

BACKGROUND: The incidence of total knee arthroplasty (TKA) surgery performed in the outpatient setting has increased as a result of improved perioperative recovery protocols, bundled payments, and challenges brought by the coronavirus disease of 2019 (COVID-19) pandemic on health systems. This study evaluates early postoperative clinical and economic outcomes of patients treated in the inpatient vs outpatient setting using the Attune Knee System (AKS). METHODS: Patients with an elective, primary TKA implanted with the AKS, from Q4 2015 to Q1 2021, were identified within the Premier Healthcare Database. The index was defined as the admission date for inpatient cases and the service day for outpatient procedures. Inpatient and outpatient cases were matched on patient characteristics. Outcomes included 90-day all-cause readmissions, 90-day knee reoperations, and index- and 90-day costs of care. Generalized linear models were used to evaluate outcomes (Reoperation: binomial distribution; costs: Gamma distribution with log link). RESULTS: Before matching, 39,337 inpatient and 9,365 outpatient cases were identified, with greater comorbidities in the inpatient cohort. The outpatient cohort had a lower average Elixhauser Index (EI) compared to the inpatient cohort (1.94 (standard deviation (SD): 1.46) vs 2.17 (SD: 1.53), p < 0.001), and the rates for each individual comorbidities were also slightly lower in the outpatient compared to the inpatient cohorts. Post-match, 9,060 patients were retained in each cohort [mean age: ~ 67, EI = 1.9 (SD: 1.5), 40% male]. Post-match comorbidity rates were similar between inpatient and outpatient cohorts (outpatient EI: 1.94 (SD: 1.44)-inpatient EI: 1.96 (SD: 1.45), p = 0.3516): in both, 54.1% of patients had an EI between 1 and 2, and 5.1% had an EI ≥ 5. No differences were observed in 3-month reoperation rates (0.6% in outpatient, 0.7% in inpatient cohort). Index and post-index 90-day costs were lower in the outpatient vs inpatient cases [(savings for index-only costs: $2,295 (95% CI: $1,977-$2,614); 90 days post-index knee-related care only: $2,540 (95% CI: $2,205-$2,876); 90 days post-index all-cause care: $2,679 (95% CI: $2,322-$3,036)]. CONCLUSIONS: Compared to matched inpatient cases, outpatient TKA cases treated with AKS showed similar 90-day outcomes, at lower cost.

Overnight joint replacement surgery: a pilot Australian study.

BACKGROUND: With a stretched healthcare system and elective surgery backlog, measures to improve efficiency and decrease costs associated with surgical procedures need to be prioritized. This study compares the benefits of multi-disciplinary involvement in an enhanced recovery after surgery (ERAS) protocol-led overnight model following total hip replacement (THR) and total knee replacement (TKR). METHODS: Patients in each of two private hospitals undergoing THR or TKR were prospectively enrolled. One hospital (Overnight) was fully committed to the ERAS protocol implementation on all levels and formed the treatment group while in the other hospital (control), patients only had the anaesthetic and operative procedure as part of the ERAS protocol but did not follow the perioperative measures of the protocol. Outcomes on hospital length of stay (LOS), inpatient rehabilitation, functional outcomes, satisfaction, adverse events and readmission rates were investigated. RESULTS: Median LOS in the Overnight group was significantly smaller than in the control group (1 vs. 3 days, P < 0.0001). The Overnight group had lower rates of inpatient rehabilitation utilization (4% vs. 41.2%, P < 0.0001), similar improvements in functional hip and knee scores and no increased rate of adverse events or readmission. All patients in both groups were satisfied with their treatment. CONCLUSION: Overnight THR and TKR can safely be performed in the majority of patients, with a multi-disciplinary approach protocol and involvement of all perioperative stakeholders.

Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting.

BACKGROUND: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. METHODS: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. RESULTS: Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. CONCLUSIONS: Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. LEVEL OF EVIDENCE: Level III Retrospective cohort study.

No exponential rise in revision knee replacement surgery over the past 15 years: an analysis from the National Joint Registry.

OBJECTIVE: To investigate trends in the incidence rate and the main indication for revision knee replacement (rKR) over the past 15 years in the UK. METHOD: Repeated national cross-sectional study from 2006 to 2020 using data from the National Joint Registry (NJR). Crude incidence rates were calculated using population statistics from the Office for National Statistics. RESULTS: Annual total counts of rKR increased from 2,743 procedures in 2006 to 6,819 procedures in 2019 (149% increase). The incidence rate of rKR increased from 6.3 per 100,000 adults in 2006 (95% CI 6.1 to 6.5) to 14 per 100,000 adults in 2019 (95% CI 14 to 14) (122% increase). Annual increases in the incidence rate of rKR became smaller over the study period. There was a 43.6% reduction in total rKR procedures in 2020 (during the Covid-19 pandemic) compared to 2019. Aseptic loosening was the most frequent indication for rKR overall (20.7% procedures). rKR for aseptic loosening peaked in 2012 and subsequently decreased. rKR for infection increased incrementally over the study period to become the most frequent indication in 2019 (2.7 per 100,000 adults [95% CI 2.6 to 2.9]). Infection accounted for 17.1% first linked rKR, 36.5% second linked rKR and 49.4% third or more linked rKR from 2014 to 2019. CONCLUSIONS: Recent trends suggest slowing of the rate of increase in the incidence of rKR. Infection is now the most common indication for rKR, following recent decreases in rKR for aseptic loosening. Infection was prevalent in re-revision KR procedures.

Applications of Digital Health Technologies in Knee Osteoarthritis: Narrative Review.

BACKGROUND: With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR). OBJECTIVE: This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR. METHODS: In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included. RESULTS: Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively. CONCLUSIONS: For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases.

BACKGROUND: Changes to Medicare's Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA. METHODS: We identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C). RESULTS: Reviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods. CONCLUSION: RAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.

Impact of the Harm Review Service for Patients Awaiting Elective Hip and Knee Surgeries for More Than 52 Weeks.

Background The coronavirus disease 2019 (COVID-19) pandemic has affected medical practice worldwide. In the UK, elective operative lists had to be postponed to accommodate the increase in hospital admissions. Within our local trauma and orthopaedic department, a harm review clinic was developed for these postponed elective cases. The purpose of this clinic was to evaluate the impact and outcomes of the delay in elective hip and knee procedures. Methodology The elective list database of William Harvey Hospital, Kent, from April to December 2020 was retrospectively analysed. Inclusion criteria included all lower limb primary arthroplasty, elective lower limb revision surgery, and other hip and knee procedure patients waiting more than 52 weeks for surgery. All patients had telephone consultations averaging 10 minutes. Data included patients' symptoms, fresh investigations, changes in treatment plans, mental health status, and value of consultation were assessed and recorded. Results A total of 242 patients from eight lower limb consultants were analysed. Patients with hip pathology accounted for 39.2% (95 patients) versus knee pathology accounting for 60.7% (147 patients). In total, 13 (5.37%) patients reported improvement in their physical symptoms, whereas 46 (19%) felt their symptoms worsen. Overall, 26 (10.7%) patients had a change in their treatment plan following the consultation. In total, 18 (7.4%) patients required further face-to-face follow-up following the telephone consultation There were no patients who had significant physical or mental harm. Conclusions The COVID-19 pandemic has brought changes in how we practice medicine. The harm review service has been a valuable service to both patients and the orthopaedic department. This harms review clinic was able to identify changes in treatment plans for patients. A small percentage of patients required face-to-face appointments. We suggest telephone assessment should be the first mode of communication with patients. Further studies should be conducted in other specialities to determine if there are similar outcomes.

EVALUATION OF A TRI-COMPARTMENT OFFLOADER KNEE BRACE: A PROSPECTIVE STUDY IN INDIVIDUALS WITH KNEE OSTEOARTHRITIS

Purpose: Knee Osteoarthritis (KOA) is a leading cause of physical disability worldwide. Individuals who suffer from KOA experience pain, reduced mobility, and lower quality of life. Considering the upward trend in KOA diagnoses, the economic burden of knee replacement, and the surgical backlog from COVID-19, the need for alternative conservative treatments is pressing. Bracing is an economical and accessible form of conservative treatment. Traditional KOA braces only offload one knee compartment. However, over 50% of the KOA population suffers from cartilage damage in multiple compartments. The Levitation™ “Tri-Compartment Offloader” (TCO) knee brace contains embedded liquid springs that provide flexion support and extension assist to simultaneously offload joint forces in all three knee compartments. Similar to the effect of weight loss, biomechanical studies have demonstrated that the TCO provides clinically relevant reductions in tibiofemoral and patellofemoral joint contact forces ranging between 30-50%. However, there is a need to validate whether the TCO improves real world outcomes in KOA patients. Therefore, the current objective is to examine the influence of a TCO brace on knee pain and function in a population suffering from KOA. Methods: Individuals with KOA who purchased the TCO are being enrolled in the ongoing study following informed consent (n=113). Participants receive 4 online surveys administered using Qualtrics (USA). The first survey is completed before brace wear commences (0-months), and follow-up surveys are scheduled after 1-month, 3-months and 9-months of TCO brace wear. The surveys contain validated questionnaires including the Visual Analog Scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score (KOOS), EuroQol 5D-5L, International Physical Activity Questionnaire, Orthotics and Prosthetics Users Survey;as well as custom questionnaires to collect demographic information. This preliminary analysis includes 54 participants who completed the 1-month and 3-months surveys (mean age 55.7±9.1 yrs;43 male). Variables of interest include knee pain (VAS) and function (KOOS). Pain was assessed during four common activities: 1) walking on a flat surface (Flat Walking);2) rising from seated (Sit & Stand);3) going up and down stairs (Stairs);and 4) Squatting. A VAS pain score of 0 represents no pain, and 100 represents the worst pain imaginable. KOOS domains included: 1) Pain;2) Symptoms;3) function in activities of daily living (ADL);4) function in sport and recreation (S&R);and 5) knee-related quality of life (QoL). A KOOS score of 0 represents severe problems, and 100 represents no problems. Statistical analysis was conducted using SPSS (IBM, USA). Pain (VAS score) between timepoints was assessed using four one-way repeated measures ANOVAs with Bonferroni correction for multiple comparisons (α = 0.0125). Post-hoc analyses were used to compare timepoints. Effects of TCO use on knee function were assessed using Wilcoxon's signed-rank test with Bonferroni correction (α = 0.01). Results: Participants wore the TCO for an average of 5.1±3.4 hours/day, and 5.2±1.8 days/week at 1-month and 5.0±3.1 hours/day and 4.9±1.7 days/week at 3-months. One participant did not complete the 1-month survey. Further, two participants did not provide complete VAS responses (Table 1) and a number of participants did not provide answers to all KOOS domains (Table 2). Significant effects of TCO use on pain were observed during all activities (p<0.001) (Figure 1, Table 1). Post-hoc analyses indicated significantly decreased pain for all activities at 1-month (p <0.001) and 3-months (p-value range 0.001-0.01) compared to baseline (0-months). There were no significant differences in pain between 1-month and 3-months of TCO use (p-value range 0.318-1). The scores for all 5 domains of KOOS increased after 1-month and 3-months of TCO brace wear compared to baseline. TCO use resulted in a significant increase in ADL (0-1 months: p<0.001;0-3 months: p<0.001), Pain (0-1 months: p<0.001), and S&am ;R (0-1 months: p<0.002) (Figure 2, Table 2). [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: This study demonstrates that the TCO brace significantly decreased knee pain for KOA patients when worn during common daily activities. The mean difference in pain scores after 1-month of TCO wear was greater than the minimally clinically important difference (-19.9mm) for all activities suggesting a clinically significant improvement in pain. These significant reductions in pain were maintained after 3-months of TCO wear, demonstrating continued pain management benefits at 3-months. This suggests that the TCO is an effective conservative treatment option over a moderate period of time. Brace usage data indicated good compliance and consistent duration of brace wear between 1-month and 3-months, which could be a result of the continued reduction in knee pain. An improvement in all 5 dimensions of KOOS was also observed, with significant improvements in Pain, ADL, and S&R after 1-month of wearing the TCO. These findings indicate that the Levitation™ TCO brace has a strong potential to manage pain and improve knee function for patients suffering from KOA. Future work includes continued data collection and investigating the effects of the TCO on pain and function in the KOA population over a longer time period.

The impact of implementing a multicomponent recovery pathway for patients undergoing unicompartmental knee replacement on length of stay

Keywords: unicompartmental, pathway, outcomes Purpose: Unicompartmental knee replacement (UKR) is the gold standard surgical management of patients with unicompartmental osteoarthritis of the knee. As UKR surgery is less invasive, this potentially allows patients to be discharged quicker than those patients undergoing total knee replacement. During the COVID-19 pandemic, elective surgeries were postponed and new ways of working were required to restart procedures. In order to minimise the risk of exposure to COVID-19, we established a new multicomponent recovery pathway (MRP) for patients undergoing UKR to facilitate earlier discharge. Objective: To evaluate the impact of the MRP on length of stay. Methods: The MRP was introduced in August 2020 to provide day-case surgery where possible. All patients undergoing UKR at St Cross Hospital, Rugby were eligible for inclusion in the trial. Exclusion criteria was lack of support at home and uncontrolled co-morbidities. Patients who were assessed preoperatively, but unsuitable for the day-case service followed all other aspects of the enhanced recovery pathway (ERP). The ERP included a new anaesthetic protocol of prilocaine spinal anaesthesia, limiting tourniquet use, and multimodal postoperative analgesia. From a physiotherapy perspective, new individualised pre-operative assessment and education sessions were introduced, with mobilisation commencing on the day of surgery. Patients were discharged with their knee in full extension and returned at day 4 for postoperative review and initiation of flexion. Data was collected prospectively for patients receiving the MRP and compared to a historical cohort from the previous year. Primary outcome was hospital length of stay (LOS). LOS data was assessed for normality and analysed using the students t-test. Results: Following introduction of the MRP 30 patients underwent UKR and were included in the analysis. Patients in the MRP group were significantly older (65.6 vs. 60.1 years, p < 0.05), although no other baseline differences were observed. Whilst there was a reduction in the use of general anaesthesia (30% vs 59%, p = 0.0917) and tourniquets (53% vs 68%, p = 0.3925), this did not reach statistical significance although there was a significant increase in the use of Prilocaine (30% vs 0%, p < 0.01). Following the introduction of the MRP, LOS reduced significantly (1.4 vs 2.9 days, p < 0.001), with no significant differences observed in joint range of motion (ROM) between groups. Within the MRP group, 9 patients (30%) received all key components (prilocaine spinal anaesthesia, no tourniquet and enhanced physiotherapy), 8 of which were discharged as day-case. Conclusion(s): The MRP was successful in reducing LOS in patients undergoing UKR, with no impact on joint ROM. The biggest impact was observed for those patients who received all components. Future work should explore methods to improve compliance with the pathway to maximise patient benefit. Impact: The positive results seen through introducing the MRP has a number of potential benefits. Alongside a reduction in LOS with benefits to patients and cost savings to the trust, the additional bed capacity released will allow increased throughput of patients which could be significant for the waiting list accrued as a result of the cessation of elective surgery due to Covid-19. Funding acknowledgements: n/a

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

INTRODUCTION: We estimated the number of primary total hip and knee replacements (THR and TKR) that will need to be performed up to the year 2060. METHODS: We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the volume of primary THRs (n=94,936) and TKRs (n=100,547) performed in 2018. We projected future numbers of THR and TKR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060. RESULTS: By 2060, THR and TKR volume would increase from 2018 levels by an estimated 37.7% (n=130,766) and 36.6% (n=137,341), respectively. For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70-79 years (44.6% males, 41.2% females); 80-89 years (112.4% males, 85.6% females); 90 years and older (348.0% males, 198.2% females). CONCLUSION: By 2060 demand for hip and knee joint replacement is estimated to increase by almost 40%. Demand will be greatest in older patients (70+ years), which will have significant implications for the health service requiring forward planning given that morbidity and resource use is higher in this population. These issues, coupled with two waves of COVID-19, will impact the ability of health services to deliver timely joint replacement to many patients for a number of years, requiring urgent planning.

Ring-fenced arthroplasty unit: The need of the hour during winter and a pandemic crisis

Aim: Winter pressures along with the COVID-19 pandemic, have caused cancellation of elective services, prolonged waiting times, patient dissatisfaction and financial implications. Length of stay (LOS) following joint replacements is variable. The availability of ring-fenced beds and enhanced recovery protocol (ERP) can improve these outcomes. The performance of a stand-alone arthroplasty unit in an acute NHS Trust was assessed regarding safety, LOS and complications. Method: Patient data was collected for total hip & knee replacements (TJAs) between the months of December to March of 2018-19 and 2019- 20. Demographics, ASA, transfusion rates, LOS and 90-day reattendance was analysed. Modified ERP implemented in late 2019 included changes in analgesia and early post-operative mobilisation. The performance was then compared with DGHs within the region. Results: In 2019-20, of 280 TJAs performed, there was a mean LOS of 43 hours. This shows a reduction compared with LOS of 69 hours in 2018-19, where 288 TJAs were performed. In 2019-20, 74% of cases had early discharge within 36 hours of surgery, versus 24% in 2018-19. This accumulates to 333 inpatient days saved. Note that following ERP modification, 6 patients were discharged on the day of surgery. Surgery related complications within 3 months which required reattendance, were seen in only 2 patients. This unit performed an average of 335 TJA's in these winter months, the highest average in comparison to other DGHs in the East Midlands region, which had an overall average of 165 cases. Conclusions: A ring-fenced arthroplasty service with adherence to ERP significantly decreases LOS and increases productivity.

The effect of the COVID-19 pandemic on revision total hip and knee arthroplasty at a large academic hospital network.

We sought to quantify the impact of COVID-19 on canceled revision total joint arthroplasty (TJA) in a large academic hospital network. We performed a retrospective analysis of revision TKA and THA in a healthcare system containing 5 hospitals in a time period of 8 months prior to and 8 months after the cessation of elective surgery. We found a 30.1% decrease in revision TKA and a 6.80% decrease in revision THA. Revision TJA volume decreased in our healthcare system during COVID-19 compared to prior to the pandemic, which will likely have lasting financial and clinical ramifications for the healthcare system.

Multicenter Evaluation of Telehealth Utilization in Hip and Knee Arthroplasty Before and for One Year During the COVID-19 Pandemic.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has led to an increase in telehealth utilization across the health-care sector. It is unknown if telehealth use among hip and knee arthroplasty clinics has remained an important health-care delivery platform. The purpose of the present study was to analyze telehealth utilization before and for 1 year during the pandemic among four varied hip and knee arthroplasty clinics. METHODS: Retrospective data were available from four regionally diverse hip and knee arthroplasty centers. Data on volume of patient visits, demographics, visit types (new visit, follow-up, postoperative visit, other), and visit modality (in-person, telehealth, telephone) were available from January 2020 through April 2021. Data from the centers were analyzed as a total and separately, using chi-squared and Fisher exact tests. RESULTS: Among the four centers, there were 296,540 hip and knee arthroplasty outpatient clinic visits between January 2020 and April 2021. Of those, 15,240 (5%) were telehealth visits. Before March 2020, less than 0.1% of visits across centers occurred over telehealth. The highest utilization of telehealth visits occurred in March 2020 (>55%) and April 2020 (>25%). From August 2020 until April 2021, telehealth visits accounted for 2%-3% of total visits. Younger patients (<50 years old) were most likely to use telehealth. Follow-up and postoperative were the most likely telehealth visits. CONCLUSION: Telehealth utilization peaked during March and April of 2020 and has since reverted to near prepandemic levels. Younger patients and lower complexity visits such as postoperative or follow-up visits are more likely to use telehealth.

Persistent postoperative opioid use after total hip or knee arthroplasty: A systematic review and meta-analysis.

PURPOSE: To identify the proportion of patients with continued opioid use after total hip or knee arthroplasty. METHODS: This systematic review and meta-analysis searched Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts for articles published from January 1, 2009, to May 26, 2021. The search terms (opioid, postoperative, hospital discharge, total hip or knee arthroplasty, and treatment duration) were based on 5 key concepts. We included studies of adults who underwent total hip or knee arthroplasty, with at least 3 months postoperative follow-up. RESULTS: There were 30 studies included. Of these, 17 reported on outcomes of total hip arthroplasty and 19 reported on outcomes of total knee arthroplasty, with some reporting on outcomes of both procedures. In patients having total hip arthroplasty, rates of postoperative opioid use at various time points were as follows: at 3 months, 20% (95% CI, 13%-26%); at 6 months, 17% (95% CI, 12%-21%); at 9 months, 19% (95% CI, 13%-24%); and at 12 months, 16% (95% CI, 15%-16%). In patients who underwent total knee arthroplasty, rates of postoperative opioid use were as follows: at 3 months, 26% (95% CI, 19%-33%); at 6 months, 20% (95% CI, 17%-24%); at 9 months, 23% (95% CI, 17%-28%); and at 12 months, 21% (95% CI, 12%-29%). Opioid naïve patients were less likely to have continued postoperative opioid use than those who were opioid tolerant preoperatively. CONCLUSION: Over 1 in 5 patients continued opioid use for longer than 3 months after total hip or knee arthroplasty. Clinicians should be aware of this trajectory of opioid consumption after surgery.

Low-dose spinal and opioid-free anesthesia in patient with Severe Aortic Stenosis and SARS-CoV-2 infection: Case report.

The best anesthesiologic approach to severe AS patient has not been adequately studied in literature. Although the current guidelines have a cautious attitude in this regard, Combined Spinal-Epidural Anesthesia (CSEA) has proved to be a safe technique. Therefore, we would like to provide our experience with a severe AS and COVID-19 patient.

D-Dimer Levels Are Not Elevated in SARS-CoV-2 IgG Positive Patients Undergoing Elective Orthopedic Surgery.

INTRODUCTION: In acute COVID-19, D-Dimer levels can be elevated and those patients are at risk for thromboembolic events. This study aims to investigate differences in preoperative D-Dimer levels in SARS-CoV-2 IgG positive and negative patients undergoing primary total knee and total hip replacement (TJA) or spine surgery. METHODS: D-Dimer levels of 48 SARS-CoV-2 IgG positive and 718 SARS-CoV-2 IgG negative spine surgery patients were compared to those of 249 SARS-CoV-2 IgG positive and 2102 SARS-CoV-2 IgG negative TJA patients. Patients were assigned into groups based on D-Dimer levels as follows: <200 ng/mL, 200-400 ng/mL, and >400 ng/mL D-Dimer Units (DDU). RESULTS: D-Dimer levels did neither differ significantly between SARS-CoV-2 IgG positive spine surgery patients and TJA patients (p = 0.1), nor between SARS-CoV-2 IgG negative spine surgery and TJA patients (p = 0.7). In addition, there was no difference between SARS-CoV-2 IgG positive and negative spine surgery patients and SARS-CoV-2 IgG positive and negative TJA patients (p = 0.3). CONCLUSIONS: There is no difference in D-Dimer levels between SARS-CoV-2 IgG positive and negative patients and there does not seem to be any difference for different orthopedic specialty patients. Routine testing of D-Dimer levels is not recommended for patients undergoing elective orthopedic surgery.

Both younger and elderly patients in pain are willing to undergo knee replacement despite the COVID-19 pandemic: a study on surgical waiting lists.

PURPOSE: To identify factors influencing patient's availability to re-schedule primary total knee replacement (TKR) or revision (RKR) surgery after the lockdown (March-May 2020) during the COVID-19 pandemic. METHODS: A prospective cohort study through a telephone survey was performed in 156 patients (143 for primary and 13 for revision) included in the TKR and RKR surgical waiting list before March 2020. Contact of each patient with COVID-19, stress and anxiety, perceived pain, and function were obtained in the interviews, and also the preference of each patient to have re-scheduled surgery (early or late). Finally, we registered their response (acceptance or refusal) when surgery was effectively re-scheduled. RESULTS: 88 out of 156 patients waiting for knee replacement (76/143 of those waiting for TKR, 12/13 of those waiting for RKR) declared themselves ready for surgery in less than 1 month. When re-scheduled, 115 patients underwent surgery and 41 refused. Significantly different preferences were found for age (more prone to surgery if under 65), revision surgery (more readily available), pain (7.9 ± 1.7/10 in NRS in those undergoing surgery, 5.6 ± 2.3/10 in those refusing, p = 0.000), or COVID-19 diagnosis, but not other close contact with COVID-19, comorbidities, stress, or anxiety. A logistic regression model confirmed that revision surgery (OR 9.33), perceived severe pain (OR 5.21), and age under 65 years (OR 5.82) were significantly associated with patient preference. The probability of patients over 65 to prefer early surgery reached 60% only with pain at or above 9/10. CONCLUSIONS: Surgical timing preferences for knee replacement vary between patients older than 65 years (immediate surgery only when pain is intense) and younger patients (immediate surgery no matter the amount of pain). Even if COVID-19 severely stroke our population, the need for knee replacement stood in the young population and even in the aged population at risk for COVID when pain was important.

Morbidity and mortality in patients undergoing lower limb arthroplasty surgery during the initial surge of the COVID-19 pandemic in the UK at a single-speciality orthopaedic hospital.

AIMS: The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. METHODS: Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. RESULTS: There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. CONCLUSION: An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323-329.