The impact of primary total hip and knee replacement on frailty: an observational prospective analysis.

BACKGROUND: Osteoarthritis is a prevalent condition in frail older adults that requires hip or knee replacement in many patients. The aim of the study was to determine the impact of hip and knee arthroplasty on frailty. METHODS: In this prospective short-term study, we used data from 101 participants of the ongoing Special Orthopaedic Geriatrics (SOG) trial, funded by the German Federal Joint Committee (GBA). Frailty, measured by Fried's Physical Frailty Phenotype (PFP), was assessed preoperatively, 7 days postoperatively, 4-6 weeks and 3 months after hip and knee arthroplasty. ANOVA with repeated measures and post-hoc tests for the subgroups were used for the statistical analysis. RESULTS: Of the 101 participants, 50 were pre-frail (1-2 PFP criteria) and 51 were frail (≥ 3 PFP criteria) preoperatively. In the pre-frail group, the PFP score decreased from 1.56 ± 0.50 (median 2) preoperatively to 0.53 ± 0.73 (median 0) 3 months after surgery (p < 0.001). The PFP score in the frail cohort decreased from 3.39 ± 1.45 (median 3) preoperatively to 1.27 ± 1.14 (median 1) 3 months postoperatively (p < 0.001). While the PFP score of the pre-frail participants increased 7 days after surgery, the PFP score of the frail group decreased significantly. CONCLUSION: Pre-frail individuals often regain robustness and patients with frailty are no longer assessed as frail after surgery. Joint replacement is an effective intervention to improve frailty in hip and knee osteoarthritis. TRIAL REGISTRATION: This study is part of the Special Orthopaedic Geriatrics (SOG) trial, German Clinical Trials Register DRKS00024102. Registered on 19 January 2021.

[Shoulder endoprosthesis-When and which model?] / Schulterendoprothetik ­ Wann welches Modell?

Advanced omarthritis or an irreparable lesion of the rotator cuff are indications for the implantation of a shoulder prosthesis. Several models are available and the choice of model depends on the specific pathology of the patient. Preoperative medication management must be taken into account in rheumatism patients. The correct aftercare is essential for the proper functioning of the prosthesis.

Special orthopaedic geriatrics (SOG) - a new multiprofessional care model for elderly patients in elective orthopaedic surgery: a study protocol for a prospective randomized controlled trial of a multimodal intervention in frail patients with hip and knee replacement.

BACKGROUND: Due to demographic change, the number of older people in Germany and worldwide will continue to rise in the coming decades. As a result, the number of elderly and frail patients undergoing total hip and knee arthroplasty is projected to increase significantly in the coming years. In order to reduce risk of complications and improve postoperative outcome, it can be beneficial to optimally prepare geriatric patients before orthopaedic surgery and to provide perioperative care by a multiprofessional orthogeriatric team. The aim of this comprehensive interventional study is to assess wether multimorbid patients can benefit from the new care model of special orthopaedic geriatrics (SOG) in elective total hip and knee arthroplasty. METHODS: The SOG study is a registered, monocentric, prospective, randomized controlled trial (RCT) funded by the German Federal Joint Committee (GBA). This parallel group RCT with a total of 310 patients is intended to investigate the specially developed multimodal care model for orthogeriatric patients with total hip and knee arthroplasty (intervention group), which already begins preoperatively, in comparison to the usual orthopaedic care without orthogeriatric co-management (control group). Patients ≥70 years of age with multimorbidity or generally patients ≥80 years of age due to increased vulnerability with indication for elective primary total hip and knee arthroplasty can be included in the study. Exclusion criteria are age < 70 years, previous bony surgery or tumor in the area of the joint to be treated, infection and increased need for care (care level ≥ 4). The primary outcome is mobility measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are morbidity, mortality, postoperative complications, delirium, cognition, mood, frailty, (instrumental) activities of daily living, malnutrition, pain, polypharmacy, and patient reported outcome measures. Tertiary outcomes are length of hospital stay, readmission rate, reoperation rate, transfusion rate, and time to rehabilitation. The study data will be collected preoperative, postoperative day 1 to 7, 4 to 6 weeks and 3 months after surgery. DISCUSSION: Studies have shown that orthogeriatric co-management models in the treatment of hip fractures lead to significantly reduced morbidity and mortality rates. However, there are hardly any data available on the elective orthopaedic care of geriatric patients, especially in total hip and knee arthroplasty. In contrast to the care of trauma patients, optimal preoperative intervention is usually possible. TRIAL REGISTRATION: German Clinical Trials Register DRKS00024102. Registered on 19 January 2021.

[Delirium-an interdisciplinary challenge]. / Delir ­ eine interdisziplinäre Herausforderung.

BACKGROUND: Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients. DIAGNOSTIC: Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential. TREATMENT: In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.

Differences in femoral component subsidence rate after THA using an uncemented collarless femoral stem: full weight-bearing with an enhanced recovery rehabilitation versus partial weight-bearing.

BACKGROUND: Femoral component subsidence is a known risk factor for early failure of total hip arthroplasty (THA) using cementless stems. The aim of the study was to compare an enhanced recovery concept with early full weight-bearing rehabilitation and partial weight-bearing on stem subsidence. In addition, the influence of patient-related and anatomical risk factors on subsidence shall be assessed. METHODS: One hundred and fourteen patients underwent primary cementless THA and were retrospectively analyzed. Sixty-three patients had an enhanced recovery rehabilitation with early full weight-bearing and 51 patients had rehabilitation with partial weight-bearing (20 kg) for 6 weeks. Postoperative subsidence was analyzed on standing pelvic anterior-posterior radiographs after 4 weeks and 1 year. Subsidence was measured in mm. Anatomical and prosthetic risk factors (stem size, canal flare index, canal fill ratio as well as BMI and demographic data) were correlated. RESULTS: Femoral stem subsidence rate was significantly higher for the group with an enhanced recovery concept compared to the group with partial weight-bearing at the first radiological follow up after 4 weeks [2.54 mm (SD ± 1.86) vs. 1.55 mm (SD ± 1.80)] and the second radiological follow up after 1 year [3.43 mm (SD ± 2.24) vs. 1.94 (SD ± 2.16)] (p < 0.001, respectively). Stem angulation > 3° had a significant influence on subsidence. Canal flare index and canal fill ratio showed no significant correlation with subsidence as well as BMI and age. CONCLUSION: In the present study, cementless stem subsidence was significantly higher in the group with enhanced recovery rehabilitation compared to partial weight-bearing. Small absolute values and differences were demonstrated and therefore possibly below clinical relevance. Anatomical radiological parameters and anthropometric data did not appear to be risk factors for stem subsidence.

Postoperative delirium is a risk factor for complications and poor outcome after total hip and knee arthroplasty.

Background and purpose - Improving health care and demographic change have resulted in a steady increase in geriatric patients undergoing total hip (THA) and knee (TKA) arthroplasty. Postoperative delirium (POD) is a frequent and severe complication after major surgery. Therefore, we analyzed the impact of POD on outcome after THA and TKA.Patients and methods - In a consecutive series of 10,140 patients who had undergone elective THA or TKA between 2011 and 2020, rates of reoperation within 90 days, readmission within 90 days, complications, and responder rate as defined by the OMERACT-OARSI criteria were compared between patients with and without POD. Multivariable logistic regression models were used to assess the relationship between POD and other postoperative complications.Results - Patients with POD showed higher rates of reoperation (12% vs. 5%), readmission (15% vs. 5%), surgical complications (7% vs. 2%), non-surgical complications (8% vs. 4%), Clavien-Dindo IV° complications (10% vs. 2%) and transfusion (14% vs. 2%). POD led to lower responder rate (76% vs. 87%) 1 year after total joint replacement. All previous comparisons statistically significant. Multivariable logistic regression analyses revealed POD as an independent risk factor for reoperation (OR = 2; CI 1-3), readmission (OR = 2; CI 2-4) and Clavien-Dindo IV° complications (OR = 3; CI 2-5).Interpretation - POD is a serious problem in elective joint replacement. Affected patients suffer more complications and show poor patient-reported outcome 1 year postoperatively. Systematic prevention strategies and standardized therapy protocols are mandatory to avoid burden to patients and healthcare providers.

Hospital Frailty Risk Score Outperforms Current Risk Stratification Models in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Models for risk stratification and prediction of outcome, such as the Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Method (ECM), the 5-factor modified Frailty Index (mFI-5), and the Hospital Frailty Risk Score (HFRS) have been validated in orthopedic surgery. The aim of this study is to compare the predictive power of these models in total hip and knee replacement. METHODS: In a retrospective analysis of 8250 patients who had undergone total joint replacement between 2011 and 2019, CCI, ECM, mFI-5, and HFRS were calculated for each patient. Receiver operating characteristic curve plots were generated and the area under the curve (AUC) was compared between each score with regard to adverse events such as transfusion, surgical, medical, and other complications. Multivariate logistic regression models were used to assess the relationship among risk stratification models, demographic factors, and postoperative adverse events. RESULTS: In prediction of surgical complications, HFRS performed best (AUC: 0.719, P < .001), followed by ECM (AUC: 0.578, P < .001), mFI-5 (AUC: 0.564, P = .003), and CCI (AUC: 0.555, P = .012). With regard to medical complications, other complications, and transfusion, HFRS also was superior to ECM, mFI-5, and CCI. Multivariate logistic regression analyses revealed HFRS as an independent risk stratification model associated with all captured adverse events (P ≤ .001). CONCLUSION: The HFRS is superior to current risk stratification models in the context of total joint replacement. As the HRFS derives from routinely collected administrative data, healthcare providers can identify at-risk patients without additional effort or expense.

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: The Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty. METHODS: In a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events. RESULTS: Patients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001). CONCLUSION: The HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense. LEVEL OF EVIDENCE: Level III-retrospective cohort study.