Postcode osteoarthritis: geographic inequities in hip and knee arthroplasty.

BACKGROUND: It is suspected that there are differences in access to orthopaedic care within New Zealand (NZ), due to inter-hospital differences in scoring thresholds for surgical eligibility. We aimed to evaluate those patients who meet the threshold for publicly funded surgery with regard to both functional disability and severity of radiographic arthritis across three different public hospitals to assess any discrepancies. METHODS: A retrospective review of prospectively collected data over a 12 month period (2018-2019) across three public hospitals (Auckland City, North Shore and Whangarei hospitals) in NZ was performed. Patients undergoing primary hip and knee arthroplasty for OA were eligible for the study. Preoperative Oxford Score and the Tonnis and Kellgren-Lawrence classification systems for hip and knees, respectively, were compared. RESULTS: A total of 274 scheduled total arthroplasties (161 hips and 113 knees) in 273 patients were included for analysis. The mean Preoperative Oxford scores for individuals with hip OA in Auckland, North Shore and Whangarei were 15.9 (SD 10.5), 14.5 (SD 6.9) and 11.9 (SD 5.7), respectively. The mean Preoperative Oxford scores for individuals with knee OA in Auckland, North Shore and Whangarei were 17.4 (SD 11.9), 18.2 (SD 6.2) and 12.7 (SD 6.9), respectively. CONCLUSION: Patients undergoing hip and knee joint replacement surgery in Whangarei hospital are, on average, more functionally impaired and have more severe radiographic arthritis than those having the same proposed surgery in Auckland and North Shore hospitals.

Safety and efficacy of intraosseous ropivacaine in lower extremity (SORE) study.

BACKGROUND: Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to develop postoperative pain regimes that allow same day mobilization and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. METHODS: This patient blinded, pilot study randomized 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration. The primary outcome for this study was arterial plasma concentration of ropivacaine. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes included immediate postoperative pain scores using the visual analogue scale and perioperative opioid equivalent consumption. RESULTS: All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/mL). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 2.93 mg/mL. This would equate to 0.18 µg/mL of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. CONCLUSIONS: This study demonstrates that IO ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilize other analgesics via the IO regional route to improve perioperative pain relief.

Tranexamic Acid in Knee Surgery Study-A Multicentered, Randomized, Controlled Trial.

BACKGROUND: Postoperative anemia following elective arthroplasty can lead to prolonged hospital stay and delays in rehabilitation and is often poorly tolerated in patients with cardiovascular disease. Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in total knee arthroplasty (TKA). However, questions over its optimal route of administration remain. METHODS: A double-blinded, placebo, multicentered, randomized, controlled trial investigating the efficacy of topical and systemic routes of a single intraoperative dose (1.5 g) of TXA was conducted. Patients undergoing primary, unilateral TKA were screened for eligibility. Eligible patients were consecutively enrolled from 5 New Zealand centers between July 2014 and November 2015. Three prospective groups running in parallel (topical TXA [tTXA], systemic TXA [sTXA], and placebo) were investigated for a primary outcome of estimated perioperative blood loss. An intention-to-treat analysis was used to compare outcomes between the study groups (P value <.05). RESULTS: One hundred and thirty-four patients across the 5 hospitals were recruited into the study. Estimated blood loss was equivalent in the 2 treatment groups, sTXA (749 mL [95% confidence interval, 637-860]) and tTXA (723 mL [620-826]). Compared to the placebo group (1090 mL [923-1257]), blood loss was significantly lower in both treatment groups (P = .001 and P = .0003, respectively). There were no significant differences in secondary outcomes, including rates of symptomatic deep vein thrombosis and pulmonary embolism (P = .759). CONCLUSION: In the setting of elective TKA, a single 1.5-g dose of tTXA given intraoperatively either systemically or topically effectively reduces blood loss without an increase in complications.

Enhanced Recovery After Surgery in elective hip and knee arthroplasty reduces length of hospital stay.

BACKGROUND: Standardized perioperative care within an Enhanced Recovery After Surgery (ERAS) programme aims to reduce postoperative morbidity and length of hospital stay (LOS). This study evaluated the effect of ERAS in patients undergoing elective, primary total hip and knee arthroplasty (THA and TKA) in a New Zealand public hospital. METHODS: Data collected prospectively on patients who had undergone THA and TKA in an ERAS programme (ERAS: August-December 2013) were compared to a retrospective cohort of patients managed in a traditional perioperative care environment (control: June-August 2012). The Breakthrough Series Model for Improvement provided a framework to implement components of the ERAS protocol. The primary outcome was median LOS. Secondary outcomes included 30-day readmission rates, complications and cost. RESULTS: There were 206 patients who met the eligibility criteria (106 ERAS, 100 control). There were no significant differences in baseline characteristics. After the implementation of ERAS, median LOS was reduced by 1 day (5 control versus 4 ERAS; P < 0.001). Short-term complications were similar (P = 0.372) as were readmission rates (P = 0.258). Cost analysis identified ERAS patients to have reduced cost overall. CONCLUSIONS: ERAS in THA and TKA has been shown to be safe and effective in improving recovery through shorter hospital stay.

Health economics in Enhanced Recovery After Surgery programs.

PURPOSE: The Enhanced Recovery After Surgery (ERAS) program aims to combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. In conjunction with its clinical benefits, it has been suggested that ERAS reduces costs through shorter convalescence and reduced morbidity. Nevertheless, few studies have evaluated the cost-effectiveness of ERAS programs. The aim of this systematic review, therefore, is to evaluate the claims that ERAS is cost-effective and to characterize how these costs were reported and evaluated. SOURCE: The electronic databases, MEDLINE(®) and EMBASE™, were searched from inception to April 2014. PRINCIPAL FINDINGS: Seventeen studies met the inclusion criteria and were included for review. Enhanced Recovery After Surgery protocols in various abdominal surgeries have been investigated, including colorectal, bariatric, gynecological, gastric, pancreatic, esophageal, and vascular surgery. All studies reported cost savings associated with hastening recovery and reducing morbidity and complications. All studies included in this review focused primarily on in-hospital costs, with some attempting to account for readmission costs and follow-up services. In all but two studies, the breakdown of cost data for the individual studies was poorly detailed. CONCLUSIONS: In conclusion, ERAS protocols appear to be both clinically efficacious and cost effective across a variety of surgical specialties in the short term. Nevertheless, studies reporting out-of-hospital cost data are lacking. Further research is required to determine how best to evaluate both medium- and long-term costs relating to ERAS pathways while taking quality of life data into account.

Review article: Perioperative care in enhanced recovery for total hip and knee arthroplasty.

Enhanced recovery pathways for total hip and knee arthroplasty can reduce length of hospital stay and perioperative morbidity. 22 studies were reviewed for identification of perioperative care interventions, including preoperative (n=4), intra-operative (n=8), and postoperative (n=4) care interventions. Factors that improve outcomes included use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status and provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems and tranexamic acid, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery.