A meta-analysis assessing time for return to sport following hip resurfacing.

BACKGROUND: Hip resurfacing arthroplasty (HRA) is associated with excellent functional outcomes and return to pre-disease level of activity. The time for return to sport (RTS) following HRA remains unknown. The aim of this meta-analysis was to establish the time for RTS following HRA. METHODS: A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on HRA and RTS, in the English language, published from the inception of the database to October 2020. In addition, a manual search was performed of relevant sports medicine and orthopaedic journals, and the bibliographies reviewed for eligible trials. All clinical trials reporting on time to RTS following HRA were included. Data relating to patient demographics, methodological quality, operation type, RTS, clinical outcomes, and complications were recorded by two independent reviewers. The PRISMA guidelines for reporting meta-analyses was used to undertake this study. RESULTS: The initial literature search identified 1559 studies and nine further studies were found. Of these, 11 studies with a total of 659 patients matched the inclusion criteria. Two studies involving a total of 94 patients demonstrated an overall pooled proportion of 91.8% (95% CI 71.8-100) of patients RTS by three months post-operatively. Four studies including a total of 265 patients determined a pooled proportion of 96.8% (95% CI 91.0-99.7) of patients able to RTS by the 6-month post-operative stage. Pooled proportion analysis from all 11 studies comprising 659 patients showed 90.9% (95% CI 82.2-96.9) of patients were able to RTS by final follow up of 3 years. CONCLUSION: Pooled proportion analysis showed an increasing number of patients were able to RTS after HRA over the first one year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 80% of patients were able to RTS at 6 to 12 months after HRA. The findings of this meta-analysis will enable more informed discussions between patients and healthcare professionals about time for RTS following HRA.

Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials.

PURPOSE: The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. METHODS: A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. RESULTS: 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7-5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1-3.1) with an OR of 1.9 (95% CI = 1.1-3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12-0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4-5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10-0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7-9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50-19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60-3.60, p = 0.36) did not differ between the two groups. CONCLUSION: Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. LEVEL OF EVIDENCE: meta-analysis, Level II.

Debridement, antibiotics, and implant retention in non-oncological femoral megaprosthesis infections: minimum 5 year follow-up.

PURPOSE: Megaprostheses are increasingly utilised outside of the oncological setting, and remain at significant risk of periprosthetic joint infection (PJI). Debridement, antibiotic, and implant retention (DAIR) is an established treatment for PJI, however its use in non-oncological patients with femoral megaprostheses has not been widely reported. There are significant differences in patient physiology, treatment goals, and associated risks between these patient cohorts. METHODS: We identified 14 patients who underwent DAIR for a PJI of their femoral megaprostheses, between 2000 and 2014, whom had their index procedure secondary to non-oncological indications. Patients were managed as part of a multidisciplinary team, with our standardised surgical technique including exchange of all mobile parts, and subsequent antibiotic therapy for a minimum of 3 months. Patients were followed up for a minimum of 5 years. RESULTS: Patients included six proximal femoral replacements, five distal femoral replacements, and three total femoral replacements. No patients were lost to follow-up. There were six males and eight females, with a mean age of 67.2 years, and mean ASA of 2.3. Nine patients (64.3%) successfully cleared their infection following DAIR at a minimum of 5 year follow-up. Five patients (35.7%) required further revision surgery, with four patients cleared of infection. No patients who underwent DAIR alone suffered complications as a result of the procedure. CONCLUSIONS: The use of DAIR in these complex patients can lead to successful outcomes, but the risk of further revision remains high. The success rate (64.3%) remains on par with other studies evaluating DAIR in megaprostheses and in primary arthroplasty. This study indicates judicious use of DAIR can be an appropriate part of the treatment algorithm. LEVEL OF EVIDENCE: II.

Time for return to sport following total knee arthroplasty: a meta-analysis.

INTRODUCTION: The frequency of total knee arthroplasty (TKA) is increasing, particularly in younger and more active patients. In these patients, there may be greater functional demands, with an expectation to return to sporting activities (RTS) following TKA. There is a paucity of data on the time to RTS following TKA and the aim of this meta-analysis is to determine the time to RTS following TKA. METHODS: Using the PRISMA guidelines, an electronic search of PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trails was performed on TKA and RTS in English language, published since the inception of the database to 31st October 2020. Data evaluating the time to RTS and functional outcomes were recorded by two authors independently that were included in the analysis. Pooled analysis using random effect model on overall proportions at the different time intervals and at the end of the follow-up was carried out for all studies. RESULTS: In total, 1,611 studies were retrieved from literature search. Of these, nine studies met the inclusion criteria with 1,307 patients. Two studies with 148 patients demonstrated an overall pooled proportion of 18.7% (95% CI 8.2-32.3%) of patients RTS at 3 month post-TKA; Three studies reported RTS rate at 6 months 70.% (95% CI 48-88.4). Two studies with 123 patients demonstrated an overall pooled proportion of 84.0% (95% CI 77.1-89.9%) patients RTS at 12 months. 986 patients returned to sport from total of 1307, with an overall adjusted proportion return to sport of 87.9 (95% CI 80.5-93.8%) at the end of follow-up; mean 14 months (range 3-36 months). CONCLUSION: Patients undergoing TKA were found to successfully RTS, pooled proportion analysis showed an increasing rate of RTS with time, at a mean of 14 months following TKA, where 87.9% of patients had returned to sports. The findings of this study will enable more informed discussions and rehabilitation planning between patients and clinicians on RTS following TKA.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

INTRODUCTION: We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS: An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS: Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION: We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Artificial intelligence and surgical innovation: lower limb arthroplasty.

The number of patients requiring hip and knee arthroplasty continues to rise each year. Patients are living longer and expecting to remain active into later life following joint replacement. Developments in computer-assisted surgery and robotic technology may optimise surgical outcomes and patient satisfaction following lower limb arthroplasty. The use of artificial intelligence in healthcare is rapidly growing and has gained momentum in lower limb arthroplasty. This article reviews the use of artificial intelligence and surgical innovation in lower limb arthroplasty, with a particular focus on robotic-assisted surgery in total knee arthroplasty.

Use of preoperative opioids increases duration of hospital stay following elective lower limb arthroplasty. - A snapshot of UK practice.

This study is one of the first in the UK where to assess the link between pre-operative opioid use and length of stay or complications. The primary objective was to test our hypothesis; that low dose pre-operative opioids will not lead to an increase in complications and LOS in lower limb arthroplasty patients. 640 records were found and 625 patients were included whom received elective primary or revision surgery. It was found that Pre-operative opioids >12 MED does increase LOS.

Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up.

PURPOSE: The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria. METHODS: A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2 years. Stratified variable analysis of the groups was also performed. RESULTS: There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52 months and 27 months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P < 0.001) favoured ACL reconstruction with LEAT compared to ACL reconstruction alone. Sports with frequent change of direction maneuvers and higher rates of ACL injury (rugby, soccer, skiing) favoured ACL reconstruction with LEAT versus ACL reconstruction alone (P = 0.001). No significant difference in re-operation rate or type of surgery was found between the two surgical groups after propensity matching but 13 patients in the ACL reconstruction-only group re-injured their ACL, 8 of whom required supplementary LEAT at the time of revision surgery. CONCLUSION: Patient-reported outcomes and return to multi-directional sports after ACL reconstruction favour LEAT at the time of ACL reconstruction when narrow inclusion criteria are applied.

Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection.

AIMS: The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). PATIENTS AND METHODS: We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. RESULTS: A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years' follow-up. CONCLUSION: The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110-115.