Fast Starters, Slow Starters, and Late Dippers: Trajectories of Patient-Reported Outcomes After Total Hip Arthroplasty: Results from a Dutch Nationwide Database.

BACKGROUND: The purpose of this study was to explore whether subgroups of patients with different functional recovery trajectories after total hip arthroplasty can be discerned, as well as their predictors, using data from the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Implantaten [LROI]). METHODS: We retrospectively reviewed prospectively collected Oxford Hip Scores (OHS) up to 1 year postoperatively for patients who had undergone a primary total hip arthroplasty. Latent class growth modeling was used to classify subgroups of patients according to the trajectory of functional recovery represented by the patients' OHS. We used multivariable multinomial logistic regression analysis to explore factors associated with class membership. RESULTS: A total of 6,030 patients were analyzed. Latent class growth modeling identified fast starters (fast initial improvement, high 12-month scores; 87.7%), slow starters (no initial change and subsequent improvement; 4.6%), and late dippers (initial improvement and subsequent deterioration; 7.7%). Factors associated with slow starters were female sex (odds ratio [OR], 1.63 [95% confidence interval (CI), 1.14 to 2.33]) and smoking (OR, 1.95 [95% CI, 1.26 to 3.03]); an anterior approach (OR, 0.47 [95% CI, 0.29 to 0.78]) had a protective effect against a less favorable response. Factors associated with late dippers were age of >75 years (OR, 1.62 [95% CI, 1.22 to 2.15]), smoking (OR, 1.68 [95% CI, 1.17 to 2.42]), American Society of Anesthesiologists (ASA) grade of III or IV (OR, 1.41 [95% CI, 1.05 to 1.91]), obesity (OR, 1.96 [95% CI, 1.43 to 2.69]), poorer EuroQol-5 Dimensions (EQ-5D) Self-Care (OR, 1.41 [95% CI, 1.09 to 1.82] for "some problems" and OR, 2.90 [95% CI, 1.39 to 6.03] for "unable"), poorer EQ-5D Anxiety/Depression (OR, 1.31 [95% CI, 1.00 to 1.71] for "moderately" and OR, 1.86 [95% CI, 1.06 to 3.24] for "extremely"), poorer EQ-5D visual analog scale (OR, 0.91 [95% CI, 0.86 to 0.97] per 10 points), direct lateral approach (OR, 2.18 [95% CI, 1.58 to 3.02]), and hybrid fixation with a cemented acetabular implant (OR, 1.79 [95% CI, 1.00 to 3.21]). CONCLUSIONS: We discerned fast starters, slow starters, and late dippers after total hip arthroplasty. Female sex, older age, obesity, higher ASA grades, and worse EQ-5D scores were associated with a less favorable response to total hip arthroplasty, as well as hybrid fixation (cemented acetabular implant) and direct lateral approach. Anterior approach had a protective effect against a less favorable response. However, all subgroups experienced functional improvement following total hip arthroplasty. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The risk of revision after total hip arthroplasty in young patients depends on surgical approach, femoral head size and bearing type; an analysis of 19,682 operations in the Dutch arthroplasty register.

BACKGROUND: Total hip arthroplasty (THA) is used increasingly in younger patients. There is little knowledge about the effect of THA characteristics on risk of revision, especially in young patients. Therefore, we studied the influence of both patient-related and surgical factors on the risk of revision using data from the Dutch Arthroplasty Registry (LROI). METHODS: All patients younger than 55 years with a primary THA implanted in the Netherlands between 2007 and 2017 were selected (n = 19,682). The covariates age, sex, primary diagnosis, ASA-classification, surgical approach, fixation method, bearing type, head size and year of surgery were entered into Cox proportional hazards models to calculate hazard ratios for the risk of revision. RESULTS: The overall 5-year survival of primary THA was 95.3% (95% CI, 94.9-95.6). Use of the anterior approach resulted in a lower risk of revision than the use of the posterolateral approach (HR: 0.66, 95% CI: 0.47-0.92). THAs with a head diameter ≥ 38 mm had a higher risk of revision (HR: 1.90, 95% CI: 1.33-2.72) than THAs with 32 mm heads. Use of MoM bearings resulted in an increased risk when compared to C-PE (HR: 1.76, 95% CI: 1.27-2.43). CONCLUSION: The risk of revision in patients younger than 55 years depends on surgical approach, head size and bearing type. The anterior approach resulted in a decreased risk of revision, whereas use of ≥38 mm heads and MoM bearings resulted in an increased risk of revision for any reason.

Dynamics of an orthopaedic team: Insights to improve teamwork through a design thinking approach.

BACKGROUND: Supporting teamwork in healthcare is a way to foster both the quality and safety of care, and better working conditions for all the team members. Although increasing attention is paid to this topic on a general level, there is less knowledge about its unfolding in orthopaedic units and its translation to interventions. OBJECTIVE: To identify concrete opportunities for teamwork intervention through a design thinking approach by analysing the teamwork dynamics of an orthopaedic team. METHODS: An adaptation of the learning history method, comprising shadowing, observations and interviews involving 26 orthopaedic team members at a top clinical teaching hospital in the Netherlands, was applied. A thematic analysis was conducted to derive themes that describe team dynamics and to subsequently extrapolate opportunities for intervention. RESULTS: We identified five themes and translated them into four design opportunities for intervention, namely: a) Improve daily rounds by reducing cognitive overload and promoting confidence; b) Improve collaboration by building empathy; c) Connect the patient with the professional team; and d) Support changes by fostering learning. Suggestions for concrete actions are presented for each opportunity. CONCLUSIONS: Opportunities to improve teamwork among healthcare professionals, specifically those in orthopaedics, revolve around the creation of common knowledge, the fostering of mutual understanding, and the design of tools and activities that support these processes.

Patients who underwent total hip or knee arthroplasty are more physically active than the general Dutch population.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) bring relief of pain and functional disability to patients with end-stage osteoarthritis, and however, the literature on their impact on patients' level of physical activity (PA) is scarce. Cross-sectional study in patients who underwent THA/TKA surgery in the preceding 6-22 months and a random sample of persons aged >40 years from the Dutch general population, participating in a national survey. PA in minutes per week (min/week) and adherence to the Dutch recommendation for PA (NNGB yes/no) were measured by the short questionnaire to assess health-enhancing PA. Multivariable linear (total min/week) and logistic regression analyses (meeting recommendations PA), adjusting for confounders, were performed for THA and TKA separately. In total, 258 THA [62.3% female, aged 69.4 (9.1)] and 221 TKA [65.7% female, aged 69.5 (8.9)] patients and 4373 persons from the Dutch general population [51.4% female, aged 58.9 (11.6)] were included. The presence of THA was associated after adjusting for age, sex, BMI education and musculoskeletal comorbidities, with more total min/week spent on PA (THA 13.8% increase, 95% CI 1.6-27.6%), whilst both TJA groups were associated with adhering to NNGB (THA: OR 1.79, 95% CI 1.26-2.56; TKA: OR 1.73, 95% CI 1.20-2.51). As this study used questionnaires to compare the PA of THA/TKA patients to the general population, some recall and selection bias might have been induced. After surgery, overall, TJA patients are more likely to adhere NNGB than a representative sample of persons >40 years from the Dutch general population.

Clinical and Wear Analyses of 9 Large Metal-on-Metal Total Hip Prostheses.

BACKGROUND: Metal-on-Metal (MoM) total hip arthroplasties (THA) are associated with pseudotumor formation and high revision rates. This prospective study analysed the clinical and wear analyses of 9 large Metal-on-Metal (MoM) total hip arthroplasties (THA) to understand the underlying mechanisms of failure. The MoM bearings were revised for multiple reasons; the main reason was pseudotumor formation. MATERIALS AND METHODS: From 2006 till 2010 the Reinier de Graaf Hospital implanted 160 large head M2a-Magnum™ (Biomet Inc. Warsaw, Indiana, USA) THAs in 150 patients. The first year, 9 bearings were revised and analysed at the Biomechanics Section, Hamburg University of Technology, Germany. We performed clinical (Harris Hip Score, radiographic analysis, blood cobalt and chromium) and wear analysis (implant, tissue and fluid) of the 9 bearings. Since this study did not fall under the scope of the Medical Research Involving Human Subjects Act in The Netherlands, no ethical approval was necessary. In this prospective study all patient details were anonymized by the corresponding author, all other authors were blinded during the research and wear analyses. Patients with bilateral MoM implants were excluded. RESULTS: The 9 bearings had a median (IQR) survival of 41.0 (25) months in situ. From these bearings, three showed no noticeable wear. The median (IQR) head wear volume was 3.2 (3.6) mm3 and maximum wear depth 0.02 (0.02) mm. For the cup the median (IQR) wear volume was 0.23 (0.3) mm3 with a maximum wear depth of 0.03 (0.05) mm. CONCLUSION: An early identification of parameters related to failure of the MoM THA, such as pain, decreased range of motion, radiographic changes and high levels of blood cobalt and chromium is of great importance for patient's quality of life. Especially now patients and surgeons face the long term effects of all these bearings still in situ. This study reports the clinical and wear analyses of 9 MoM THA. In the majority of this group the reason for revision was pseudotumor formation. Most bearings showed signs of wear, however with a great diversity in clinical analysis, in inclination angle, serum cobalt and chromium levels as well as wear analysis. For a better understanding of the underlying mechanisms related with failure, more wear analyses of revised MoM bearings are necessary as well as a frequent follow-up of the patients with a MoM bearing.

No effect of the infiltration of local anaesthetic for total hip arthroplasty using an anterior approach: a randomised placebo controlled trial.

Only limited data are available regarding the infiltration of local anaesthetic for total hip arthroplasty (THA), and no studies were performed for THA using the anterior approach. In this prospective, randomised placebo-controlled study we investigated the effect of both standard and reverse infiltration of local anaesthetic in combination with the anterior approach for THA. The primary endpoint was the mean numeric rating score for pain four hours post-operatively. In addition, we recorded the length of hospital stay, the operating time, the destination of the patient at discharge, the use of pain medication, the occurrence of side effects and pain scores at various times post-operatively. Between November 2012 and January 2014, 75 patients were included in the study. They were randomised into three groups: standard infiltration of local anaesthetic, reversed infiltration of local anaesthetic, and placebo. There was no difference in mean numeric rating score for pain four hours post-operatively (p = 0.87). There were significantly more side effects at one and eight hours post-operatively in the placebo group (p = 0.02; p = 0.03), but this did not influence the mobilisation of the patients. There were no differences in all other outcomes between the groups. We found no clinically relevant effect when the infiltration of local anaesthetic with ropivacaine and epinephrine was used in a multimodal pain protocol for THA using the anterior approach.

Which patient characteristics influence length of hospital stay after primary total hip arthroplasty in a 'fast-track' setting?

After implementation of a 'fast-track' rehabilitation protocol in our hospital, mean length of hospital stay for primary total hip arthroplasty decreased from 4.6 to 2.9 nights for unselected patients. However, despite this reduction there was still a wide range across the patients' hospital duration. The purpose of this study was to identify which specific patient characteristics influence length of stay after successful implementation of a 'fast-track' rehabilitation protocol. A total of 477 patients (317 female and 160 male, mean age 71.0 years; 39.3 to 92.6, mean BMI 27.0 kg/m(2);18.8 to 45.2) who underwent primary total hip arthroplasty between 1 February 2011 and 31 January 2013, were included in this retrospective cohort study. A length of stay greater than the median was considered as an increased duration. Logistic regression analyses were performed to identify potential factors associated with increased durations. Median length of stay was two nights (interquartile range 1), and the mean length of stay 2.9 nights (1 to 75). In all, 266 patients had a length of stay ≤ two nights. Age (odds ratio (OR) 2.46; 95% confidence intervals (CI) 1.72 to 3.51; p < 0.001), living situation (alone vs living together with cohabitants, OR 2.09; 95% CI 1.33 to 3.30; p = 0.002) and approach (anterior approach vs lateral, OR 0.29; 95% CI 0.19 to 0.46; p < 0.001) (posterolateral approach vs lateral, OR 0.24; 95% CI 0.10 to 0.55; p < 0.001) were factors that were significantly associated with increased length of stay in the multivariable logistic regression model.

The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty.

The aim of the study was to examine the relationship between comorbidities and pain, physical function and health-related quality of life (HRQoL) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A cross-sectional retrospective survey was conducted including 19 specific comorbidities, administered in patients who underwent THA or TKA in the previous 7-22 months in one of 4 hospitals. Outcome measures included pain, physical functioning, and HRQoL. Of the 521 patients (281 THA and 240 TKA) included, 449 (86 %) had ≥1 comorbidities. The most frequently reported comorbidities (>15 %) were severe back pain; neck/shoulder pain; elbow, wrist or hand pain; hypertension; incontinence of urine; hearing impairment; vision impairment; and cancer. Only the prevalence of cancer was significantly different between THA (n = 38; 14 %) and TKA (n = 52; 22 %) (p = 0.01). The associations between a higher number of comorbidities and worse outcomes were stronger in THA than in TKA. In multivariate analyses including all comorbidities with a prevalence of >5 %, in THA dizziness in combination with falling and severe back pain, and in TKA dizziness in combination with falling, vision impairments, and elbow, wrist or hand pain was associated with worse outcomes in most of the analyses. A broad range of specific comorbidities needs to be taken into account with the interpretation of patients' health status after THA and TKA. More research including the ascertainment of comorbidities preoperatively is needed, but it is conceivable that in particular, the presence of dizziness with falling, pain in other joints, and vision impairments should be assessed and treated in order to decrease the chance of an unfavorable outcome.

Severe Wear and Pseudotumor Formation Due to Taper Mismatch in a Total Hip Arthroplasty: A Case Report.

CASE: We describe the case of a seventy-six-year-old woman who had undergone bilateral total hip arthroplasty with Zweymüller-Metasul prostheses in 1996. After a fall sixteen years after the index procedures, radiographs suggested a taper fracture of the left total hip arthroplasty. However, revision surgery showed pseudotumor formation, with no evidence of taper fracture. Analysis of the prosthesis showed massive wear of the male stem taper caused by a mismatch between the stem taper and the head taper. CONCLUSION: This case vividly demonstrates how taper size mismatch can cause dramatic metal wear and increased release of metal ions, resulting in pseudotumor formation.