Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study.

BACKGROUND: Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice. METHODS: From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was 'days alive and at home up to 30 days after surgery' (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice. RESULTS: Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3-5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25-27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%). CONCLUSION: Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if 'buy-in' from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov ( NCT03540667 ).

The Transverse Acetabular Ligament as an Intraoperative Guide to Cup Abduction.

BACKGROUND: The success of a total hip arthroplasty relies on optimal acetabular cup placement to ensure mating of the femoral head and acetabular cup throughout all positions of the hip joint. Poor cup placement is associated with dislocation, impingement, microseparation, component loosening, and accelerated wear due to rim loading. This study examined a novel method of using the transverse acetabular ligament (TAL) to guide cup inclination during primary total hip arthroplasty. METHODS: A descriptive study using 16 hips from 9 cadavers. A computer navigation system measured inclination and version of the acetabular component in 3 positions with the lower edge of cup: (1) flush with, (2) 5 mm proximal to, and (3) 5 mm distal to free border of the TAL. RESULTS: The median inclination angles were 44° in position (1), 30° in position (2), and 64° in position (3). The median anteversion angle for all positions was 19°. CONCLUSION: Cup inclination was acceptable when the lower edge of the cup was flush or within 5 mm proximal to the TAL.