The impact of total hip arthroplasty on sexual satisfaction in female patients: a prospective before-and-after cohort study.

PURPOSE: Despite the high rate of sexual limitation in female patients with hip osteoarthritis, evidence reporting sexual satisfaction after hip arthroplasty in women is limited. This study aimed to assess the impact of surgery on sexual satisfaction in women who undergo elective total hip arthroplasty (THA). As a secondary objective, we measured the effect of THA on different factors that could be related to sexual limitation and satisfaction. METHODS: We designed a prospective before-and-after cohort study in which all consecutive women undergoing THA were screened for inclusion. Patients answered a ten question specifically designed questionnaire before and after surgery. An independent analysis was performed for each question through a McNemar-Bowker test for paired proportions. RESULTS: Fifty-six patients completed the protocol and were available for analysis at the end of the study. Sexual satisfaction increased from 29% before surgery to 93% after the procedure (p < 0.001). All questions related to physical limitations demonstrated significant improvement after surgery. In addition, psychological aspects of limitation including fear of pain and injury, or perception of attractiveness, showed significant recovery as well. CONCLUSION: There is a high rate of patients reporting limitations and disabilities during sexual activities among women with osteoarthritis. THA represents a positive impact on sexual functioning both in its physical and psychological aspects, thus increasing satisfaction rates in female patients. Surgeons should include these elements in the conversation with patients before and after surgery.

Extended thromboprophylaxis for hip or knee arthroplasty. Does the administration route and dosage regimen affect adherence? A cohort study.

PURPOSE: Prevention of thromboembolic disease requires patients' adherence to the extended thromboprophylaxis scheme. Oral anticoagulants are expected to improve adherence as a result of their route of administration; however, this assumption is yet to be confirmed. The purpose of this study was to assess the impact of the route of administration and dosage regimen on the compliance to the prescription. MATERIALS AND METHODS: This prospective cohort study included hip and knee arthroplasty patients who received pharmacological extended thromboprophylaxis with one daily injection, one daily oral tablet, or two daily oral tablets. A telephonic questionnaire was applied 35 days after the day of the surgery. Patients who omitted one or more doses of medication during the follow-up period were classified as "non-adherent." Differences of adherence rates were assessed. RESULTS: Five hundred and twenty patients were included: 153 received Apixaban (oral, twice a day), 155 Enoxaparin (injectable, once a day), and 212 Rivaroxaban (oral, once a day). Patients receiving oral once a day medication was more compliant compared with those who received an oral medication twice a day. Non-adherence rates were 3.2 and 9.2%, respectively (p = 0.033). No significant differences (p = 0.360) were found between oral once a day and injectable once a day medication. CONCLUSIONS: The number of daily doses prescribed was related to adherence to extended chemical prophylaxis, while the route of administration did not seem to have a significant impact. Strategies to promote outpatient compliance must be implemented, especially when regimes including more than one daily dose are prescribed.

Perceived skills for sports performance after primary hip arthroplasty: a cross-sectional study.

PURPOSE: Recommendations arising from existing literature regarding restrictions and benefits of sporting activities after joint replacement surgery vary widely. As hip arthroplasty patients are becoming increasingly active, their expectations about post-operative function are constantly evolving. The aim of this study is to identify the perception of patients regarding their performance in sports activities after hip arthroplasty. METHODS: This cross-sectional study included all patients undergoing primary hip arthroplasty, for any diagnosis, between January 2009 and January 2016. By applying a telephone survey, practice of sports before surgery, resumption after surgery, level of performance, and causes of non-resumption of sports activities were assessed. RESULTS: Data of 531 patients were obtained. Of these, 13% were engaged in sports before surgery. The most frequently practiced sports were golf (27.5%) and tennis (22%). Of the 72 patients that practiced sports, only 44.4% (30 patients) returned to this activity after surgery. Nonetheless, 71% of these patients reported to have an equal or better athletic performance than before surgery. The main causes reported by patients not to return to sports were the fear of injury and recommendation of the surgeon. CONCLUSIONS: A significant number of patients return to sports after hip arthroplasty and most of them perceive a good athletic performance after surgery. These findings should enrich the pre-operative assessment of patient's expectations, particularly for those who wish to resume physical activity.

Thromboprophylaxis for Hip Revision Arthroplasty: Can We Use the Recommendations for Primary Hip Surgery? A Cohort Study.

The risk of thromboembolic events after hip revision arthroplasty might be higher than in primary hip arthroplasty. However, evidence regarding the use of thromboprophylaxis in revisions is scarce. The purpose of this study is to determine whether thromboprophylaxis recommendations for primary arthroplasty produce similar results in hip revision arthroplasty. This comparative cohort study retrospectively analyzed consecutive patients undergoing primary hip arthroplasty and hip revision surgery between March 2004 and December 2015, who received thromboprophylaxis according to local clinical practice guidelines for primary hip arthroplasty. The prevalence of deep vein thrombosis and pulmonary embolism and the presence of major bleeding events were assessed during hospitalization and at 3 months after discharge and compared between groups. The overall prevalence of thromboembolic events in the hip revision surgery cohort and in the primary hip cohort was 1.62% and 1.35%, respectively ( P = .801). The 38.4% of hip revision patients and 20.3% of primary hip patients presented major bleeding events. Thromboembolic disease outcomes with the use of a standardized thromboprophylaxis regimen were similar in both cohorts, regardless of the high variability of hip revision surgery and the increased risk of complications. Implementation of this regimen is recommended in patients requiring joint replacement revision surgery.

Adherencia a las guías internacionales de tromboprofilaxis en pacientes sometidos a cirugía ortopédica mayor en Colombia: Resultados del Registro DEIMOS / Adherence to the international thromboprophylaxis guidelines in patients undergoing major orthopaedic surgery in Colombia: Results of the DEIMOS registry

Introducción A pesar de que la implementación de guías de práctica clínica se relaciona con la disminución en la incidencia de eventos tromboembólicos pacientes sometidos a cirugía ortopédica mayor (COM), la adherencia a la tromboprofilaxis sigue siendo baja. El objetivo de este trabajo es describir la adherencia a la 8ª edición de las guías de American College of Chest Physicians (ACCP) en Colombia. Materiales y métodos Se presentan los resultados del registro DEIMOS para Colombia. Este estudio longitudinal, multicéntrico, multinacional evaluó la adherencia a las recomendaciones de tromboprofilaxis intrahospitalaria y extendida de la 8ª edición de las guías ACCP después de COM, mediante un seguimiento realizado entre 4 y 6 semanas postoperatorias. Resultados De los 244 pacientes incluidos en el registro DEIMOS para Colombia, 240 completaron el seguimiento: 108 pacientes de reemplazo total de rodilla (RTR), 77 de reemplazo total de cadera (RTC) y 59 de cirugía por fractura de cadera (FC). La adherencia intrahospitalaria fue de 80.5% (IC 95%: 71.7-89.4) para RTC, 82.4% (IC 95%: 75-2-89-6) para RTR y 94.9% (IC 95%: 89.3-100.0) para FC. La adherencia extendida fue de 75.3% (IC 95%: 65.7-85-0) para RTC, 73.1% (IC 95%: 64.8-81.5) para RTR y 93.2% (IC 95%: 86.8-99.6) para FC. Discusión El registro DEIMOS para Colombia evidencia una adecuada adherencia a la tromboprofilaxis después de cirugía por FC. Sin embargo, la adherencia al régimen extendido después de RTC y RTR es baja. Es necesario implementar esfuerzos adicionales para mejorar la protección de estos pacientes después del alta hospitalaria.

Background Patients who undergo major orthopaedic surgery have an elevated risk of venous thromboembolism (VTE). International guidelines recommendations for VTE prevention have shown to be effective in reducing the frequency of thromboembolic events, but compliance to these recommendations is still low. The purpose of the present study is to report the adherence to the American College of Chest Physicians (ACCP) guidelines 2008 in Colombia. Material and methods A report is presented on the Colombian results for the DEIMOS registry. This is a multinational, multicentre, observational, longitudinal study. Twenty orthopaedic wards were asked to include consecutive patients who were admitted for major orthopaedic surgery. Patient demographics, surgical information, type of anaesthesia and VTE prophylaxis were prospectively recorded, and the use of VTE prevention methods was assessed during the following visits. Adherence to the 2008 ACCP guidelines was then determined. Results A total of 244 patients were included in Colombia, and 240 of them had a complete follow-up. The analysis included 108 total knee arthroplasties, 77 hip replacements and 59 hip fracture surgeries. Adherence to 2008 ACCP guidelines for in-hospital prophylaxis was 80.5% (95% CI; 71.7-89.4) for hip arthroplasty, 82.4% (95% CI; 75.2-89.6) for knee arthroplasty, and 94.9% CI; 89.3-100.0) for hip fracture surgeries. Adherence for extended prophylaxis was 75.3% (95% CI; 65.7-85.0) for hip arthroplasties, 73.1% (95% CI; 64.8-81.5) for knee arthroplasties, and 93.2% (95% CI; 86.8-99.6) for hip fracture surgery. Discussion The DEIMOS registry reports good compliance to VTE prophylaxis guidelines after hip fracture surgery in Colombia. However, adherence to extended prophylaxis guidelines is still low after total hip and knee arthroplasties. Efforts should be made to improve the protection of these patients after hospital discharge.

A multimodal approach prevents instability after total hip arthroplasty: A 1 year follow-up prospective study.

INTRODUCTION: Joint dislocation is one of the most frequent complications after hip arthroplasty. Multiple strategies have demonstrated ability to prevent instability when used in isolation, but the effect when more than one intervention is implemented has not been measured. The purpose of this study is to assess the rate of dislocation after implementation of a protocol of combined strategies for prevention of instability. MATERIALS AND METHODS: Consecutive patients undergoing primary total hip replacement for hip osteoarthritis between February 2012 and June 2014 were included. A multimodal protocol including patient education, use of large femoral heads, posterior soft-tissue repair, and intraoperative adjustment of limb length and hip offset was applied. Dislocation episodes were documented trough medical records review and a telephonic follow-up at 3 and 12 months after surgery. RESULTS: During the period of study 331 patients were included, mean age was 66 years and 68.8% were females. Only 0.91% of patients were lost to follow-up. Eighty-nine percent of patients received all interventions. Cumulative dislocation rate at 3 months was 0.60% and 0.90% at 12 months. CONCLUSIONS: The implementation of a multimodal protocol for prevention of prosthesis instability produces a low rate of dislocation, which compares favorably with benchmarks. We recommend the use of a combination of multiple interventions to prevent this complication.

Bilateral Hip Arthroplasty: When Is It Safe to Operate the Second Hip? A Systematic Review.

INTRODUCTION: Patients with degenerative hip disease frequently present with bilateral involvement that requires surgical management. The main goal when treating these patients is to achieve the maximum efficiency without increasing risk of perioperative complications; therefore, the decision regarding the best moment to operate the second hip becomes relevant. Although studies have addressed this topic, whether a simultaneous or staged surgery should be performed remains controversial. The purpose of this study was to determine, based on available evidence, the optimum strategy in terms of safety to operate the second hip in patients with bilateral involvement. MATERIALS AND METHODS: A meta-analysis was planned. A systematic review of the literature was performed including clinical trials or observational analytical studies comparing the safety of bilateral arthroplasty performed simultaneously or staged by measuring major and minor complications. The appropriateness of a meta-analysis was evaluated through the detailed analysis of the risk of bias and clinical heterogeneity of the included studies. RESULTS: Thirteen studies were selected after the systematic review. A wide variability in the methodological designs was found with a critical risk of bias in most of them. Considerable heterogeneity was detected in defining staged surgery in the cointerventions and how the outcomes were defined and measured. In response to these findings, a meta-analysis was considered not appropriate. The results showed no differences in the risk of mortality or systemic complications in young and healthy patients between simultaneous or staged surgeries. However, increased risk of complications for staged surgeries performed during the same hospitalization was observed. CONCLUSIONS: Available evidence is very heterogeneous and the quality of evidence is low. The available evidence supports the performance of simultaneous hip arthroplasty in selected patients (not older than 65 years, ASA 1-2, without cardiovascular comorbidities) and suggests the avoidance of staged surgeries within the same hospitalization.

Peri-articular injection of an analgesic mixture in primary total hip arthroplasty: an effective strategy for pain control during the first post-operative day.

BACKGROUND: Previous studies of soft tissue infiltration in hip arthroplasty present variable results. The purpose of this study is to identify whether injection of an analgesic mixture improves pain management during the immediate post-operative period. MATERIALS AND METHODS: This cohort study compared 129 patients that received peri-articular soft tissue injection with 20 ml of 0.25% bupivacaine and 2 ml of ketorolac (30 mg/1 ml) in 28 ml of saline solution, with 71 patients who did not received injections. Pain intensity in the Verbal Analog Scale (VAS), opioid titration, and consumption (mg morphine equivalents) in the post-anaesthetic care unit (PACU) and during the first post-operative day were assessed for both groups. All patients received the same analgesia protocol. RESULTS: Median VAS score in the PACU was 4 (IQR 2-7) in the injection group and 7 (IQR 4-8) in the non-injection group (p = 0.001). Median opioid titration was 0 mg for the injection group and 2.6 mg for the non-injection group (p = 0.011). In the first post-operative day, the difference in VAS scores between groups was statistically significant (p = 0.009), but there was no difference in opioid consumption. CONCLUSION: Soft tissue injection with local anesthetics and non-steroidal anti-inflammatory drugs allows adequate pain control in the immediate post-operative period and reduces the requirement for opioid consumption. We recommend the implementation of this safe and effective strategy in post-operative pain management after primary hip arthroplasty. LEVEL OF EVIDENCE: Level II, cohort study.

A retrospective study on the relationship between altered native acetabular angle and vertical implant malpositioning.

PURPOSE: Acetabular cup positioning in extreme angles of vertical position affects both stability and long-term survivorship of total hip arthroplasty. The purpose of this study is to determine whether native Sharp's angle is associated with an increased abduction angle of the acetabular component. METHODS: Consecutive patients who underwent primary total hip replacement between February 2012 and August 2015 were included. Vertical positioning of acetabular implant in the antero-posterior post-operative radiographs were measured. The proportion of implants positioned outside the safe zone (40° ± 10°) was calculated and through a multivariate analysis, Sharp's angle and other factors possibly associated with cup malpositioning were evaluated. RESULTS: Five hundred twenty-eight hip arthroplasties were analyzed. Prevalence of cup malpositioning was 7.6% and 25 patients had an altered native acetabular angle. An altered pre-operative Sharp's angle was associated with a higher risk of vertical malpositioning of the acetabular component (OR 2.51 IC 95%: 1.17-5.39) (p = 0.02). Body mass index, surgeon's volume, size of the implant, gender, pre-operative diagnose and age, were not associated with the position of the cup. CONCLUSIONS: The alteration of the Sharp's angle as an indicator of hip dysplasia in native hips increases the odds of acetabular cup malpositioning. Other factors explored did not correlate with the position of the acetabular prosthesis. Systematic assessment of Sharp's angle should be included in the pre-operative planning of primary hip arthroplasty.

Screening for Infection Before Revision Hip Arthroplasty: A Meta-analysis of Likelihood Ratios of Erythrocyte Sedimentation Rate and Serum C-reactive Protein Levels.

INTRODUCTION: Diagnosing periprosthetic joint infection (PJI) before revision hip arthroplasty is critical to ensure effective treatment of patients undergoing surgery for reasons other than infection. The main objective of our study is to determine whether the erythrocyte sedimentation rate (ESR) and the serum C-reactive protein (CRP) level are sufficient to use for testing to rule out infection in patients undergoing revision hip surgery. METHODS: We performed a systematic review of the literature in the MEDLINE, Ovid, and Embase databases. We included studies in which the investigators used the ESR (>30 mm/h) and serum CRP level (>10 mg/L) for the diagnosis of PJI of the hip. We obtained meta-estimates of sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). RESULTS: From 511 articles, we analyzed 12 studies in which the investigators reported data on 2,736 patients. Sensitivity and specificity for the ESR were 0.860 (95% confidence interval [CI], 0.825 to 0.890) and 0.723 (95% CI, 0.704 to 0.742), respectively, and for the CRP level were 0.869 (95% CI, 0.835 to 0.899) and 0.786 (95% CI, 0.769 to 0.803), respectively. For the ESR, LR+ was 3.42 (95% CI, 2.55 to 4.59) and LR- was 0.22 (95% CI, 0.12 to 0.41). For the CRP level, LR+ was 4.18 (95% CI, 3.42 to 5.11) and LR- was 0.20 (95% CI, 0.12 to 0.32). DISCUSSION: With a low pretest probability of PJI, a negative test result for either the ESR or CRP level is enough to rule out infection before revision hip arthroplasty. LEVEL OF EVIDENCE: III.

Data Quality in Institutional Arthroplasty Registries: Description of a Model of Validation and Report of Preliminary Results.

BACKGROUND: Arthroplasty registries are a relevant source of information for research and quality improvement in patient care and its value depends on the quality of the recorded data. The purpose of this study is to describe a model of validation and present the findings of validation of an Institutional Arthroplasty Registry (IAR). METHODS: Information from 209 primary arthroplasties and revision surgeries of the hip, knee, and shoulder recorded in the IAR between March and September 2015 were analyzed in the following domains. Adherence is defined as the proportion of patients included in the registry, completeness is defined as the proportion of data effectively recorded, and accuracy is defined as the proportion of data consistent with medical records. A random sample of 53 patients (25.4%) was selected to assess the latest 2 domains. A direct comparison between the registry's database and medical records was performed. RESULTS: In total, 324 variables containing information on demographic data, surgical procedure, clinical outcomes, and key performance indicators were analyzed. Two hundred nine of 212 patients who underwent surgery during the study period were included in the registry, accounting for an adherence of 98.6%. Completeness was 91.7% and accuracy was 85.8%. Most errors were found in the preoperative range of motion and timely administration of prophylactic antibiotics and thromboprophylaxis. CONCLUSION: This model provides useful information regarding the quality of the recorded data since it identified deficient areas within the IAR. We recommend that institutional arthroplasty registries be constantly monitored for data quality before using their information for research or quality improvement purposes.

Primary Joint Arthroplasty Surgery: Is the Risk of Major Bleeding Higher in Elderly Patients? A Retrospective Cohort Study.

BACKGROUND: Increased risk of bleeding after major orthopedic surgery (MOS) has been widely documented in general population. However, this complication has not been studied in elderly patients. The purpose of this study is to determine whether the risk of major bleeding after MOS is higher in elderly patients, compared with those operated at a younger age. METHODS: This retrospective cohort study included total hip and total knee arthroplasty patients operated during 5 consecutive years. The main outcome was the occurrence of major bleeding. Patients with other causes of bleeding were excluded. Relative risks (RRs) and confidence intervals (CIs) were calculated, and a multivariate analysis was performed. RESULTS: A total of 1048 patients were included, 56% of patients were hip arthroplasties. At the time of surgery, 553 (53%) patients were older than 70 years. Patients aged >70 years showed an increased risk of major bleeding (RR: 2.42 [95% CI: 1.54-3.81]). For hip arthroplasty, the RR of bleeding was 2.61 (95%CI: 1.50-4.53) and 2.25 (95% CI: 1.03-4.94) for knee arthroplasty. After multivariate analysis, age was found to be independently associated with higher risk of major bleeding. CONCLUSION: According to European Medicines Agency criteria, patients aged ≥70 years are at a higher risk of major bleeding after MOS, result of a higher frequency of blood transfusions in this group of patients. Standardized protocols for blood transfusion in these patients are still required.

Worldwide adherence to ACCP guidelines for thromboprophylaxis after major orthopedic surgery: A systematic review of the literature and meta-analysis.

INTRODUCTION: Increased risk of venous thromboembolism following major orthopedic surgery (MOS) is well described. The American Academy of Chest Physician (ACCP) has generated evidence-based recommendations for thromboprophylaxis; however, there is a gap between guidelines recommendations and clinical practice. The aim of this study is to compare worldwide adherence rates to the last 4 editions of ACCP guidelines for thromboprophylaxis after MOS. MATERIALS AND METHODS: A systematic review of literature and meta-analysis was performed. Studies reporting adherence to ACCP guidelines between January 2004 and October 2014 were included. Adherence rates after MOS for in-hospital (IH), extended (EXT), and global thromboprophylaxis (in-hospital plus extended) were assessed. RESULTS: Of 3993 titles, 13 studies reporting data of 35,303 patients were selected. Studies assessing the 6th, 7th or 8th editions of ACCP guidelines were found. No studies evaluating the 9th edition were available. For MOS, global adherence rates for the 6th, 7th and 8th editions were 62% (95% CI: 61%-63%), 70% (95% CI: 69%-71%), and 42% (95% CI: 41%-43%), respectively. Likewise, in-hospital adherence was 52% (95% CI: 50%-54%), 51% (95% CI: 50%-52%) and 85% (95% CI: 84%-86%). For extended prophylaxis, adherence rates were reported only for the 8th edition (59%; 95% CI: 58%-60%). CONCLUSIONS: Adherence to ACCP recommendations for thromboprophylaxis during hospitalization has increased over time. Nevertheless, adherence rates to global thromboprophylaxis decrease due to an insufficient implementation of recommendations after discharge.

Thromboprophylaxis after major orthopedic surgery: Improving compliance with clinical practice guidelines.

INTRODUCTION: Identifying risk factors and strategies for the prevention of deep venous thromboembolism in major orthopedic surgery has allowed the development of Clinical Practice Guidelines (CPGs). Currently, there is a gap between clinical practice and the implementation of the recommendations of CPGs. The purpose of this paper is to report the impact of the implementation of improvement strategies on adherence to venous thromboembolism (VTE) prophylaxis guidelines. MATERIALS AND METHODS: We defined 3 quality indicators to assess the adequate use of thromboprophylaxis according to CPGs. We obtained a baseline measurement and identified several barriers for adherence. Six improvement strategies to promote adherence to CPGs were designed and applied. A systematic monitoring of these indicators was performed in real time and a description of the data was completed for patients undergoing primary joint replacement of the hip, knee and shoulder, during February 2012 and August 2014. RESULTS: Data from 773 patients were obtained. In the first trimester, the average of adherence was: 98.3% for medical order in the post-operative note, 60.3% for opportune administration and 67% for adherence to therapy at home. In the trimester, the rates of adherence were 100%, 95.7% and 100% respectively. CONCLUSIONS: Combined strategies for improvement of adherence to VTE prophylaxis is associated with higher compliance with clinical practice guidelines.

Evaluación intraoperatoria de los cambios de longitud y offset durante el reemplazo total cadera / Intra-operative evaluation of offset in hip replacement: device design

Introducción: la recuperación de la longitud del miembro inferior y del offset después del reemplazo total de cadera es fundamental para el buen resultado del procedimiento. Algunos métodos descritos para restablecer estos parámetros no son precisos y tienen ciertas limitaciones. El objetivo de este artículo es presentar un nuevo instrumento calibrador para uso intraoperatorio. Materiales y métodos: se diseñó y desarrolló un instrumento calibrador que permite realizar mediciones de longitud de la extremidad y offset durante la artroplastia de cadera. Para establecer la concordancia de este método con las mediciones radiológicas, se utilizó el instrumento en 39 procedimientos de reemplazo total de cadera Resultados: se encontró que el promedio de las diferencias en la medición de longitud fue de 0,05 mm y para las mediciones del offset el promedio fue 2,43 mm, con un nivel de concordancia alto (κ = 0,96 para longitud y κ = 0,54 para offset). Discusión: se observa que el calibrador es una herramienta intraoperatoria útil y precisa para la determinación de longitud y offset intraoperatorios en comparación con la radiografía posoperatoria.