Long-term survivorship and results in lower limb arthroplasty: a registry-based comparison study.

INTRODUCTION: Popularity of joint replacement surgery due to ever aging population surges the demand for a proper national joint registry. Our Chinese University of Hong Kong - Prince of Wales Hospital (CUHK-PWH) joint registry has passed the 30th year. The aims of this study are 1) summarize our territory-wide joint registry which has passed the 30th year since establishment and 2) compare our statistics with other major joint registries. METHODS: Part 1 was to review the CUHK-PWH registry. Demographic characteristics of our patients who underwent knee and hip replacements had been summarized. Part 2 was a series of comparisons with registries from Sweden, UK, Australia and New Zealand. RESULTS: CUHK-PWH registry captured 2889 primary total knee replacements (TKR) (110 (3.81%) revision) and 879 primary total hip replacements (THR) (107 (12.17%) revision). Median Surgery time of TKR was shorter than THR. Clinical outcome scores were much improved after surgery in both. Uncemented of hybrid in TKR were most popular in Australia (33.4%) and 40% in Sweden and UK. More than half of TKR and THR patients showed the highest percentage with ASA grade 2. New Zealand reflected the best cumulative percentage survival 20 years after surgery of 92.2%, 76.0%, 84.2% survivorship 20 years after TKR, unicompartmental knee replacement (UKR) and Hip. CONCLUSION: A worldwide accepted patient-reported outcome measure (PROM) is recommended to develop to make comparisons among registries and studies feasible. Completeness of registry data is important and useful to improve surgical performance through data comparisons from different regions. Funding from government on sustaining registries is reflected. Registries from Asian countries have yet to be grown and reported.

Impact of Coronavirus Disease-2019 Protocols on Primary and Revision Total Knee Arthroplasty.

Background: Surgical site infection (SSI) after total knee arthroplasty (TKA) is associated with increased morbidity and healthcare expenditures. During the coronavirus disease-2019 (COVID-19) pandemic, our institution intensified hygiene standards, including greater glove, personal protective equipment (PPE), and mask use. We assessed the effect of these changes on SSI rates in primary total knee arthroplasty (pTKA) and revision total knee arthroplasty (rTKA). Patients and Methods: A retrospective review was performed identifying TKA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic when no restriction on operative services was in place and were further analyzed during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods after full operative services were restored. Results: A total of 3,398 pTKA (pre-pandemic: 1,943 [57.2%]; pandemic: 1,455 [42.8%]) and 454 rTKA (pre-pandemic: 229 [50.4%]; pandemic: 225 [49.6%]) were included. For primary cases, superficial and deep SSI rates were similar before and during COVID-19; however, for revision TKA, the incidence of all (-0.32%, p = 0.035) and superficial (-0.32%, p = 0.035) SSIs decreased during COVID-19. Primary TKA had longer operative times (p < 0.001) and shorter length of stay (LOS; p < 0.001) during COVID-19. Both pTKA (p < 0.001) and rTKA (p = 0.003) were discharged to skilled nursing facilities less frequently during COVID-19 as well. Conclusions: After our hospital implemented COVID-19-motivated hygienic protocols, superficial SSI rates decreased in rTKA but not in pTKA. During COVID-19, patients were less likely to be discharged to skilled nursing facilities, and pTKA operative times increased. Although these changes occurred during intensified hygiene protocols, further research is needed to determine how these factors contributed to the observed changes.

Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function.

Objective: During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function. Methods: Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores. Results: Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, -4.67; (95% CI, -8.00 to -1.35)] and the 1st post-operative month [MD, -3.18; (95% CI, -5.92 to -0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, -0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, -127.67; (95% CI, -186.83 to -68.50)], shorter operation time [MD, -3.73; (95% CI, -5.98 to -1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73-1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04-5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22-3.22)]. Conclusion: Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.

Comparison of Operating Room Air Quality in Primary Versus Revision Total Knee Arthroplasty.

BACKGROUND: Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Particulate matter (PM) up to 2.5 microns can contain microbial species which may increase infection risk. Our study examines the differences in air quality and ABP count in primary total knee arthroplasty (TKA) and revision TKA (rTKA). METHODS: We analyzed primary and rTKAs in a single OR at an academic institution from January 2020 to December 2020. Procedures from March 15, 2020, to May 4, 2020, were excluded to avoid COVID-related confounding. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate the differences in variables. P values were calculated using t-test and chi-square test. RESULTS: A total of 107 TKA cases were included: 79 (73.8%) primary TKAs and 28 (26.2%) rTKAs. Time spent in an OR was significantly higher for rTKAs (primary: 176 ± 46.7 minutes vs revision: 220 ± 47.1 minutes, P < .0001). Compared to primary TKAs, rTKAs had significant percent increases in ABP rates for particles measuring 0.3 µm (+70.4%, P < .001), 0.5 µm (+97.2%, P < .0001), 1.0 µm (+53.2%, P = .001), and 2.5 µm (+30.3%, P = .017) and for PM 2.5 (+108.3%, P < .001) and PM 5.0 (+105.6%, P < .001). CONCLUSION: rTKAs had significantly longer time spent in an OR and significant percent increases in ABP rates for particles measuring 0.3 µm, 0.5 µm, and 1.0 µm compared to primary TKAs. Measurements of PM 2.5 and 5.0 (which can contain large numbers of microbes) were also significantly greater in rTKAs. Further research is needed to determine whether the size and quantity of ABPs translate to higher infection rates after rTKA.

The AAHKS Clinical Research Award: Are Minimum Two-Year Patient-Reported Outcome Measures Necessary for Accurate Assessment of Patient Outcomes After Primary Total Knee Arthroplasty?

BACKGROUND: The two-year minimum follow-up after total knee arthroplasty (TKA) required by most academic journals is based on implant survivorship studies rather than patient-reported outcome measures (PROMs). Additionally, the COVID-19 pandemic placed an unprecedented burden on patients and staff and halted asymptomatic surveillance clinic visits to minimize exposure. The purpose of this study was to determine if clinically meaningful differences were observed in PROMs beyond one year after TKA. METHODS: A retrospective review was performed on prospectively collected PROMs after 1093 primary TKAs at a suburban academic center. PROMs related to pain, function, activity level, and satisfaction were compared by subsequent follow-up intervals preoperatively, at 4 months, 1 year, and minimum 2 years using paired data analysis techniques. RESULTS: Pain with level walking and while climbing stairs improved from preoperative levels to 4-month, 1-year, and minimum 2-year follow-up. The University of California Los Angeles activity level and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement improved over the same intervals. Patient satisfaction improved over postoperative follow-up intervals (84.0%, 87.3%, and 90.9%). While PROMs improved with statistical and clinical significance preoperatively to 4-month to 1-year follow-up, improvements from 1-year to minimum 2-year follow-up were small and did not reach minimum clinically important differences for nearly all PROMs, demonstrating significant overlap of the 95% confidence intervals. CONCLUSION: While long-term follow-up after TKA remains important for implant survivorship, it appears that one-year PROMs are as clinically reliable and meaningful as two-year PROMs. Therefore, it is reasonable to question the currently accepted 2-year minimum follow-up requirement used in peer-reviewed research involving PROMs. LEVEL OF EVIDENCE: Level III.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. METHODS: An application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. RESULTS: There was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. CONCLUSION: This survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

INTRODUCTION: We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS: An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS: Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION: We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Clinical prioritisation of revision knee surgical procedures: BASK working group consensus document.

BACKGROUND: Elective orthopaedic surgery during the Covid-19 pandemic requires careful case prioritisation. We aimed to produce consensus-based guidelines on the prioritisation of revision total knee arthroplasty (TKA) procedures. METHOD: Twenty-three revision TKA scenarios were assigned priority (NHS England/Royal College of Surgeons scale) by the British Association for Surgery of the Knee (BASK) Revision Knee Working Group (n = 24). Consensus agreement was defined as ≥70% respondents (18/24) giving the same prioritisation. Two voting rounds were undertaken; procedures achieving <70% agreement were given their most commonly assigned priority. RESULTS: 18/23 procedures achieved ≥70% agreement. Three were P1a (surgery within <24 h); DAIR for sepsis, peri-prosthetic fracture (PPF) fixation and PPF-revision TKA. Three were P1b (<72 h); debridement, antibiotics and implant retention (DAIR) for a stable patient, flap coverage for an open knee, and acute extensor mechanism rupture. Eight were P2 (<4 weeks), including aseptic loosening at risk of collapse, inter-stage patients with poor functioning spacers. Five were P3 (<3 months), including second stage revision for infection, revision for instability with limited mobility. Four were P4 (can wait >3 months) e.g. aseptic loosening. CONCLUSION: Sepsis and PPF surgery are the most urgent procedures. Although most procedures should be undertaken within one to three months (P2/3), these cases represent a small revision practice volume; P4 cases (e.g. aseptic loosening without risk of collapse) make up most surgeons' caseload. These recommendations are a guideline; patient co-morbidities, Covid-19 pathways, availability of support services and multi-disciplinary team discussion within the regional revision network will dictate prioritisation.

Lessons Learned: Using the Caprini Risk Assessment Model to Provide Safe and Efficacious Thromboprophylaxis Following Hip and Knee Arthroplasty.

Two of the more common potential complications after arthroplasty are venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolus (PE), and excess bleeding. Appropriate chemoprophylaxis choices are essential to prevent some of these adverse events and from exacerbating others. Risk stratification to prescribe safe and effective medications in the prevention of postoperative VTE has shown benefit in this regard. The Department of Orthopaedic Surgery at Syosset Hospital/Northwell Health, which performs over 1200 arthroplasties annually, has validated and is using the 2013 version of the Caprini Risk Assessment Model (RAM) to stratify each patient for risk of postoperative VTE. This tool results in a culling of information, past and present, personal and familial, that provides a truly thorough evaluation of the patient's risk for postoperative VTE. The Caprini score then guides the medication choices for thromboprophylaxis. The Caprini score is only valuable if the data is properly collected, and we have learned numerous lessons after applying it for 18 months. Risk stratification requires practice and experience to achieve expertise in perioperative patient evaluation. Having access to pertinent patient information, while gaining proficiency in completing the Caprini RAM, is vital to its efficacy. Ongoing, real time analyses of patient outcomes, with subsequent change in process, is key to improving patient care.