Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis.

BACKGROUND: Total hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu + Ex) programs may reduce the number of THAs needed, but supporting data are limited. This study aimed to estimate the treatment effect of THA versus Edu + Ex on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for hip OA. METHODS: Patients who had hip OA who underwent THA or an Edu + Ex program were included in this propensity-matched study. In 778 patients (Edu + Ex, n = 303; THA, n = 475), propensity scores were based on pretreatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference (MD) in change from pretreatment to 3-month and 12-month follow-up using linear mixed models. RESULTS: The matched sample consisted of 266 patients (Edu + Ex, n = 133; THA, n = 133) who were balanced on all pretreatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (MD 35.4; 95% confidence interval [CI] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17% and 30% of patients receiving Edu + Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84% and 90% of THA patients. CONCLUSIONS: A THA provides greater improvements in pain, function, and quality of life. A notable proportion of Edu + Ex patients had clinically meaningful improvements, suggesting Edu + Ex may result in THA deferral in some patients, but confirmatory trials are needed.

Total Knee Arthroplasty Versus Education and Exercise for Knee Osteoarthritis: A Propensity-Matched Analysis.

OBJECTIVE: We estimate the treatment effect of total knee arthroplasty (TKA) versus an education and exercise (Edu+Ex) program on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for knee osteoarthritis (OA). METHODS: Patients with knee OA who had undergone TKA were matched on a 1:1 ratio with participants in an Edu+Ex program based on a propensity score fitted to a range of pretreatment covariates. After matching, between-group differences in improvement (the treatment effect) in Knee Injury and Osteoarthritis Outcome Score 12-item version (0, worst to 100, best) pain, function, and quality of life from baseline to 3 and 12 months were estimated using linear mixed models, adjusting for unbalanced covariates, if any, after matching. RESULTS: The matched sample consisted of 522 patients (Edu+Ex, n = 261; TKA, n = 261) who were balanced on all pretreatment characteristics. At 12-month follow-up, TKA resulted in significantly greater improvements in pain (mean difference [MD] 22.8; 95% confidence interval [95% CI] 19.7-25.8), function (MD 21.2; 95% CI 17.7-24.4), and quality of life (MD 18.3; 15.0-21.6). Even so, at least one-third of patients receiving Edu+Ex had a clinically meaningful improvement in outcomes at 12 months compared with 75% of patients with TKA. CONCLUSION: TKA is associated with greater improvements in pain, function, and quality of life, but these findings also suggest that Edu+Ex may be a viable alternative to TKA in a meaningful proportion of patients, which may reduce overall TKA need. Confirmatory trials are needed.

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study.

BACKGROUND: The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS: Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS: The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS: This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Meta-analysis and systematic review of clinical outcomes comparing mobile bearing and fixed bearing total knee arthroplasty.

Mobile bearing (MB) knee replacements were designed with the goal of increased conformity and decreased bearing wear. We conducted a meta-analysis and systematic review of randomized controlled trials comparing outcomes of MB and fixed bearing (FB) total knee arthroplasty (TKA). We identified 14 studies reporting our primary outcome of Knee Society Scores (KSS). We also pooled data for post-operative range of motion (ROM) and Hospital for Special Surgery scores (HSS). The standard difference in mean outcome scores for KSS and HSS demonstrated no difference between groups (P = .902, and P = .426 respectively). Similarly, the pooled data for ROM showed no difference between groups (P = .265). The results of this study found no significant differences between clinical outcomes of MB and FB TKA.

Complications after minimally invasive total knee arthroplasty as compared with traditional incision techniques: a meta-analysis.

The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive surgery and standard total knee arthroplasty (TKA) approaches. We reviewed randomized controlled trials comparing minimally invasive TKA to standard TKA. After testing for publication bias and heterogeneity, the data were aggregated by random effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function scores, and Knee Society Knee scores. The combined odds ratios for complications for the minimally invasive surgery group and alignment outliers were 1.58 (95% confidence interval, 1.01-2.47; P < .05) and 0.79 (95% confidence interval, 0.34-1.82; P = .58), respectively. The standard difference in means for Knee Society scores was no different between groups. Minimally invasive knee surgery should be approached with caution.

Effect of sex and living arrangement on the timing and outcome of joint replacement surgery.

BACKGROUND: Studies have shown that women present for surgery at an older age and with greater dysfunction than do men; however, the explanation for this finding is unclear. We investigated the impact living status (alone or with another person) and sex on the timing and outcomes of hip and knee replacement surgery. METHODS: We surveyed 1722 patients undergoing primary hip or knee replacement surgery. Relevant covariates including demographic data, body mass index, sex, living status and comorbidities were recorded. We assessed joint pain and functional status before surgery and at 3 months and 1 year after surgery using the Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores for pain and function. RESULTS: In total, 22.9% (395) of all patients (29.3% of women and 14.1% of men) were living alone at the time of surgery. Compared with patients who lived with another person, those who lived alone were significantly older, had greater comorbidity and reported greater joint pain and dysfunction before surgery and 3 months and 1 year after surgery. Living alone and female sex independently predicted a greater preoperative WOMAC score, and living alone predicted an older age at the time of surgery and a poorer 1-year outcome. CONCLUSION: Patients who live alone may delay joint replacement surgery until an older age and have greater joint pain and dysfunction than those who live with another person, leading to poorer 1-year outcomes.

Relationship between body habitus and joint leptin levels in a knee osteoarthritis population.

Synovial fluid (SF) leptin has been shown to have an association with cartilage degeneration. Our objective was to examine the relationship between different measures of body habitus and SF leptin levels in an end-stage knee osteoarthritis (OA) population. Sixty consecutive patients with knee OA were surveyed prior to surgery for demographic data. Body habitus was assessed with the body mass index (BMI), waist circumference (WC), and waist-hip ratio (WHR). SF and serum samples were analyzed for leptin and adiponectin using specific ELISA. Nonparametric correlations and linear regression modeling was used to identify the relationship between the measures of body habitus and SF leptin levels. Females had greater levels of leptin than males in both the serum and SF. Significant correlations were found between SF leptin levels and BMI and WC (R(2) 0.44 and 0.38, respectively; p < 0.05). Regression modeling showed that female gender and WC were independent predictors of a greater SF leptin level independent of age, BMI, and presence of diabetes (p < 0.05). WC may be a more accurate measure of body habitus than BMI in the relationship between the metabolic effects of adipose tissue and OA.

Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial.

BACKGROUND: Home-based rehabilitation is increasingly utilized to reduce health-care costs; however, with a shorter hospital stay, the possibility arises for an increase in adverse clinical outcomes. We evaluated the effectiveness and cost of care of home-based compared with inpatient rehabilitation following primary total hip or knee joint replacement. METHODS: We randomized 234 patients, using block randomization techniques, to either home-based or inpatient rehabilitation following total joint replacement. All patients followed standardized care pathways and were evaluated, with use of validated outcome measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Short Form-36, and patient satisfaction), prior to surgery and at three and twelve months following surgery. The primary outcome was the WOMAC function score at three months after surgery. RESULTS: The mean length of stay (and standard deviation) in the acute care hospital was 6.3 +/- 2.5 days for the group designated for inpatient rehabilitation prior to transfer to that facility compared with 7.0 +/- 3.0 days for the home-based rehabilitation group prior to discharge home (p = 0.06). The mean length of stay in inpatient rehabilitation was 17.7 +/- 8.6 days. The mean number of postoperative home-based rehabilitation visits was eight. The prevalence of postoperative complications up to twelve months postoperatively was similar in both groups, which each had a 2% rate of dislocation and a 3% rate of clinically important deep venous thrombosis. The prevalence of infection was 0% in the home-based group and 2% in the inpatient group. None of these differences was clinically important. Both groups showed substantial improvements at three and twelve months, with no significant differences between the groups with respect to WOMAC, Short Form-36, or patient satisfaction scores (p > 0.05). The total episode-of-care costs (in Canadian dollars) for the inpatient rehabilitation and home-based rehabilitation arms were $14,532 and $11,082, respectively (p < 0.01). CONCLUSIONS: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the group that received home-based rehabilitation and the group that had inpatient rehabilitation. On the basis of our findings, we recommend the use of a home-based rehabilitation protocol following elective primary total hip or knee replacement as it is the more cost-effective strategy.

Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less.

BACKGROUND: Subcapital hip fractures in younger patients are generally treated with internal fixation rather than with primary hemiarthroplasty, which is generally reserved for older, low-demand patients. Avascular necrosis can occur following this injury because of disruption of the femoral head blood supply. Some believe that emergent fracture reduction is necessary to minimize the risk of avascular necrosis. The purposes of this study were (1) to investigate the functional outcomes of subcapital hip fractures in patients sixty years old or younger and (2) to compare the rates of avascular necrosis after early and delayed fracture fixation. METHODS: This retrospective study included adults in whom a subcapital hip fracture had been treated with reduction and internal fixation when they were sixty years of age or less and who had been followed clinically for a minimum of two years. The patients were divided into two groups: those treated with early fixation (within twelve hours after the injury) and those treated with delayed fixation (more than twelve hours after the injury). Functional outcomes were assessed with use of the Short Form-36 and the Western Ontario and McMaster University (WOMAC) Osteoarthritis Index. The rates of avascular necrosis were compared between the two groups. RESULTS: Thirty-eight patients (average age, 46.4 years) participated in the study. Twenty-nine patients had a displaced subcapital hip fracture. Fifteen patients underwent early fracture fixation, and the remainder underwent delayed fixation. No differences in the Short Form-36 (p = 0.68) or WOMAC (p = 0.69) scores were seen between the early and delayed fixation groups. Radiographic evidence of avascular necrosis developed in six patients treated with delayed fixation, one of whom had had an undisplaced fracture preoperatively, and in no patient treated with early fixation. The difference in the rates of avascular necrosis was significant (p = 0.03). CONCLUSIONS: Although delayed surgical treatment of subcapital hip fractures was associated with a higher rate of avascular necrosis, this complication did not significantly affect functional outcome. Longer follow-up is required to assess the effect of avascular necrosis on the development of arthritis and on long-term patient function. Although the results could be biased because patients were not randomly assigned to delayed or early fixation, the data suggest that urgent reduction and fracture fixation within twelve hours after a displaced subcapital hip fracture in high-demand patients may be associated with a reduced rate of radiographic signs of avascular necrosis.