The painful truth of waiting for hip and knee arthroplasty in Northern Ireland.

Aims: The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods: This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results: Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state "worse than death", were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion: Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care.

Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial.

AIMS: Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. METHODS: TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. RESULTS: Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. CONCLUSION: This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536-542.

Risk Factors for Significant Radiolucent Line Development in a Fully Coated Hydroxyapatite Stem.

BACKGROUND: The risk factors for and clinical impact of radiolucent lines (RLLs) in cementless total hip arthroplasty remain contentious. The aim of this work was to describe a method of classification that has clinical significance and to identify risk factors. METHODS: A cohort of 288 subjects with unrevised Corail stems (DePuy Synthes, Warsaw, IN) were reviewed with radiographs and Oxford Hip Scores at 10 years. Based on clinical experience, three groups were defined; those with no RLLs (NoRLLs), those considered to have benign RLLs (BenRLLs), and those considered to have significant RLLs (SigRLLs). SigRLLs were then compared to BenRLLs and NoRLLs to determine the validity of this classification. RESULTS: One hundred and nine (37.8%) had NoRLLs, 111 (38.5%) had BenRLLs, and 68 (23.6%) had SigRLLs. No significant difference apart from gender was noted between the occurrence of BenRLLs and NoRLLs after multinomial regression analysis, consequently the NoRLLs and BenRLLs groups were combined (NoSigRLLs) and compared to SigRLLs. Non-cross-linked polyethylene (odds ratio = 4.6, P < .001), collarless stem design (odds ratio = 9.4, P < .001), undersizing (odds ratio = 1.2, P = .028), and male sex (odds ratio = 2.1, P = .008) were risk factors for SigRLLs. Regression analysis also revealed that increasing age at operation decreased the likelihood of SigRLLs (P < .001). Patients with SigRLLs had significantly higher pain scores (P = .005) although overall Oxford Hip Scores were not significantly different (P = .364). CONCLUSION: The definition of SigRLLs proposed in this study was significantly associated with that of non-cross-linked polyethylene, absence of a collar, undersizing, and higher pain scores.

30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic: a multicentre regional analysis of 484 patients.

AIMS: Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. METHODS: This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. RESULTS: Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. CONCLUSION: Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus.Cite this article: Bone Joint Open 2020;1-7:392-397.

Are There Gender-Specific Errors in Restoration of Hip Biomechanics That Affect Outcome Following Total Hip Arthroplasty?

BACKGROUND: There are morphologic differences between males and females, which are currently underappreciated during total hip arthroplasty. We sought to assess whether these differences affected surgical process and subsequent outcome. METHODS: A total of 123 patients (75 females, 48 males) had preoperative and 1-year Oxford Hip Score (OHS) and pain scores recorded. Acetabular height and offset, femoral height and offset, and acetabular floor depth were measured on preoperative and postoperative X-rays and then compared to their normal opposite hip. Discrepancies between the replaced and normal hip X-ray measurements were then correlated with changes (the delta gain) in preoperative and 1-year postoperative OHS and pain scores. RESULTS: Postoperatively, females had significantly greater femoral height discrepancy (P = .023) which meant they were lengthened. This led to a reduced delta gain in OHS and pain score at 1 year. Males lost more acetabular offset than females (P = .002), leading to a medialized acetabular center and subsequently reduced delta gain in pain score at 1 year (P = .017). CONCLUSION: Females have a smaller femur leading to a bias toward a conservative (higher) neck cut compared with males and potential for femoral lengthening. Males have a greater acetabular floor depth compared with females and thus reaming to the true floor results in greater loss of acetabular offset. In this series, both scenarios led to reduced improvement in OHS and/or pain scores at 1 year.