Patient-relevant outcomes following elective, aseptic revision knee arthroplasty: a systematic review.

BACKGROUND: The aim of this systematic review was to summarise the evidence for the clinical effectiveness of revision knee arthroplasty (rKA) compared to non-operative treatment for the management of patients with elective, aseptic causes for a failed knee arthroplasty. METHODS: MEDLINE, Embase, AMED and PsychINFO were searched from inception to 1st December 2020 for studies on patients considering elective, aseptic rKA. Patient-relevant outcomes (PROs) were defined as implant survivorship, joint function, quality of life (QoL), complications and hospital admission impact. RESULTS: No studies compared elective, aseptic rKA to non-operative management. Forty uncontrolled studies reported on PROs following elective, aseptic rKA (434434 rKA). Pooled estimates for implant survivorship were: 95.5% (95% CI 93.2-97.7%) at 1 year [seven studies (5524 rKA)], 90.8% (95% CI 87.6-94.0%) at 5 years [13 studies (5754 rKA)], 87.4% (95% CI 81.7-93.1%) at 10 years [nine studies (2188 rKA)], and 83.2% (95% CI 76.7-89.7%) at 15 years [two studies (452 rKA)]. Twelve studies (2382 rKA) reported joint function and/or QoL: all found large improvements from baseline to follow-up. Mortality rates were low (0.16% to 2% within 1 year) [four studies (353064 rKA)]. Post-operative complications were common (9.1 to 37.2% at 90 days). CONCLUSION: Higher-quality evidence is needed to support patients with decision-making in elective, aseptic rKA. This should include studies comparing operative and non-operative management. Implant survivorship following elective, aseptic rKA was ~ 96% at 1 year, ~ 91% at 5 years and ~ 87% at 10 years. Early complications were common after elective, aseptic rKA and the rates summarised here can be shared with patients during informed consent. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020196922.

Indications and techniques for non-articulating spacers in massive bone loss following prosthetic knee joint infection: a scoping review.

INTRODUCTION: Prosthetic joint infection (PJI) is a destructive complication of knee replacement surgery (KR). In two-stage revision a spacer is required to maintain limb length and alignment and provide a stable limb on which to mobilise. Spacers may be articulating or static with the gold standard spacer yet to be defined. The aims of this scoping review were to summarise the types of static spacer used to treat PJI after KR, their indications for use and early complication rates. METHODS: We conducted a scoping review based on the Joanna Briggs Institute's "JBI Manual for Evidence Synthesis" Scoping review reported following Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, EMBASE and CINAHL were searched from 2005 to 2022 for studies on the use of static spacers for PJI after KR. RESULTS: 41 studies (1230 patients/knees) were identified describing 42 static spacer constructs. Twenty-three (23/42 [54.2%]) incorporated cement augmented with metalwork, while nineteen (19/42, [45.9%]) were made of cement alone. Spacers were most frequently anchored in the diaphysis (22/42, [53.3%]), particularly in the setting of extensive bone loss (mean AORI Type = F3/T3; 11/15 studies 78.3% diaphyseal anchoring). 7.1% (79 of 1117 knees) of static spacers had a complication requiring further surgery prior to planned second stage with the most common complication being infection (86.1%). CONCLUSIONS: This study has summarised the large variety in static spacer constructs used for staged revision KR for PJI. Static spacers were associated with a high risk of complications and further work in this area is required to improve the quality of care in this vulnerable group.

Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement: A Randomized Clinical Trial.

Importance: More than half of patients who undergo knee replacement surgery report substantial acute postoperative pain. Objective: To evaluate the efficacy and cost-effectiveness of periarticular liposomal bupivacaine for recovery and pain management after knee replacement. Design, Setting, and Participants: This multicenter, patient-blinded, pragmatic, randomized clinical superiority trial involved 533 participants at 11 institutions within the National Health Service in England. Adults undergoing primary unilateral knee replacement for symptomatic end-stage osteoarthritis were enrolled between March 29, 2018, and February 29, 2020, and followed up for 1 year after surgery. Follow-up was completed March 1, 2021. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis. Interventions: Two hundred sixty-six milligrams of liposomal bupivacaine admixed with 100 mg of bupivacaine hydrochloride compared with 100 mg of bupivacaine hydrochloride alone (control) administered by periarticular injection at the time of surgery. Main Outcome and Measures: The coprimary outcomes were Quality of Recovery 40 (QoR-40) score at 72 hours and pain visual analog scale (VAS) score area under the curve (AUC) from 6 to 72 hours. Secondary outcomes included QoR-40 and mean pain VAS at days 0 (evening of surgery), 1, 2, and 3; cumulative opioid consumption for 72 hours; functional outcomes and quality of life at 6 weeks, 6 months, and 1 year; and cost-effectiveness for 1 year. Adverse events and serious adverse events up to 12 months after randomization were also assessed. Results: Among the 533 participants included in the analysis, the mean (SD) age was 69.0 (9.7) years; 287 patients were women (53.8%) and 246 were men (46.2%). Baseline characteristics were balanced between study groups. There was no difference between the liposomal bupivacaine and control groups in QoR-40 score at 72 hours (adjusted mean difference, 0.54 [97.5% CI, -2.05 to 3.13]; P = .64) or the pain VAS score AUC at 6 to 72 hours (-21.5 [97.5% CI, -46.8 to 3.8]; P = .06). Analyses of pain VAS and QoR-40 scores demonstrated only 1 statistically significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (adjusted difference -0.54 [97.5% CI, -1.07 to -0.02]; P = .02). No difference in cumulative opioid consumption and functional outcomes was detected. Liposomal bupivacaine was not cost-effective compared with the control treatment. No difference in adverse or serious adverse events was found between the liposomal bupivacaine and control groups. Conclusions and Relevance: This study found no difference in postoperative recovery or pain associated with the use of periarticular liposomal bupivacaine compared with bupivacaine hydrochloride alone in patients who underwent knee replacement surgery. Trial Registration: isrctn.com Identifier: ISRCTN54191675.

Preoperative Severe Acute Respiratory Syndrome Coronavirus 2 Polymerase Chain Reaction Test at Between 48 and 72 Hours Preoperatively is Safe for Patients Undergoing Primary and Revision Hip and Knee Arthroplasty: A Multicentre International Study.

BACKGROUND: Patients undergoing lower limb arthroplasty who are severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive at the time of surgery have a high risk of mortality. The National Institute for Health and Clinical Care Excellence and the British Orthopaedic Association advise self-isolation for 14 days preoperatively in patients at a high risk of adverse outcomes due to COVID-19. The aim of the study is to assess whether preoperative polymerase chain reaction (PCR) for SARS-CoV-2 could be performed at between 48 and 72 hours preoperatively with specific advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission. METHODS: A multicentre, international, observational cohort study of 1,000 lower limb arthroplasty cases was performed. The dual primary outcomes were 30-day conversion to SARS-CoV-2 positive and 30-day SARS-CoV-2 mortality. Secondary outcomes included 30-day SARS-CoV-2 morbidity. RESULTS: Of the 1,000 cases, 935 (94%) had a PCR between 48 and 72 hours preoperatively. All cases were admitted to and had surgery through a COVID-free pathway. Primary knee arthroplasty was performed in 41% of cases, primary hip arthroplasty in 40%, revision knee arthroplasty in 11%, and revision hip arthroplasty in 9%. Six percent of operations were emergency operations. No cases of SARS-CoV-2 were identified within the first 30 days. CONCLUSION: Preoperative SARS-CoV-2 PCR test between 48 and 72 hours preoperatively with advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission in conjunction with a COVID-free pathway is safe for patients undergoing primary and revision hip and knee arthroplasty. Preoperative SARS-CoV-2 PCR test alone may be safe but further adequately powered studies are required. This information is important for shared decision making with patients during the current pandemic.

Systematic review and meta-analysis of bearing dislocation in lateral meniscal bearing unicompartmental knee replacement: Domed versus flat tibial surface.

BACKGROUND: Bearing dislocation is a problem following mobile bearing Oxford lateral Unicompartmental Knee Replacement (UKR). Therefore, the design of the tibial component was changed from a flat tibial surface to a domed tibial surface with a biconcave bearing to increase bearing entrapment. This systematic review compared the dislocation and revision rates of the two designs. METHODS: Two authors independently searched MEDLINE, EMBASE and ISI Web of Science, reference lists of retrieved articles, and the internet. Randomised, cohort, case-control and case studies of adult patients with lateral knee osteoarthritis treated with flat or domed Oxford lateral UKR and their outcomes were included. The overall dislocation rate and the annual revision rate (per 100 component years) were determined. RESULTS: Nine studies (937 knees) met the inclusion criteria (3 flat, 6 domed). Four studies (all domed) had a low risk of bias and five had a high risk (3 flat, 2 domed), so data should be interpreted with caution. The bearing dislocation rate decreased from 17% (flat) to 3.7% (domed). Dislocations occurred on average at 16 months and medial dislocations were most common. The revision rate excluding dislocation decreased from 1.1%pa to 0.7%pa. PROSPERO registration: CRD42019139250. CONCLUSION: Modifying the tibial component from a flat to a domed shape decreased the bearing dislocation rate to 3.7% and increased the 10 year survival rate excluding dislocation to 93%. The dislocation rate is still relatively high so bearing stability should be assessed intra-operatively and if unacceptable, a fixed bearing version of the Oxford lateral tibial component can be inserted.

The effect of obesity on revision rate in unicompartmental knee arthroplasty: a systematic review and meta-analysis.

The number of patients with knee osteoarthritis, the proportion that is obese and the number undergoing unicompartmental knee arthroplasty (UKA) are all increasing. The primary aim of this systematic review was to determine the effects of obesity on outcomes in UKA. A systematic review was performed using PRISMA guidelines and the primary outcome was revision rate per 100 observed component years, with a BMI of ≥ 30 used to define obesity. The MINORS criteria and OCEBM criteria were used to assess risk of bias and level of evidence, respectively. 9 studies were included in the analysis. In total there were 4621 knees that underwent UKA. The mean age in included studies was reported to be 63 years (mean range 59.5-72 years old)) and range of follow up was 2-18 years. Four studies were OCEBM level 2b and the average MINORS score was 13. The mean revision rate in obese patients (BMI > 30) was 0.33% pa (95% CI - 3.16 to 2.5) higher than in non-obese patients, however this was not statistically significant (p = 0.82). This meta-analysis concludes that there is no significant difference in outcomes between obese and non-obese patients undergoing UKA. There is currently no evidence that obesity should be considered a definite contraindication to UKA. Further studies are needed to increase the numbers in meta-analysis to explore activity levels, surgeon's operative data, implant design and perioperative complications and revision in more depth.Level of evidence Level III.

30-day outcome after orthopaedic surgery in patients assessed as negative for COVID-19 at the time of surgery during the peak of the pandemic.

INTRODUCTION: The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic. METHOD: A retrospective, single centre, observational cohort study of all patients undergoing surgery between 17 March 2020 and 3May 2020 was performed. Outcomes were stratified by British Orthopaedic Association COVID-19 Patient Risk Assessment Tool. Patients who were SARS-CoV-2 positive at the time of surgery were excluded. RESULTS: Overall, 96 patients assessed as negative for SARS-CoV-2 at the time of surgery underwent 100 emergency or urgent orthopaedic procedures during the study period. Within 30 days of surgery 9.4% of patients (n = 9) were found to be SARS-CoV-2 positive by nasopharyngeal swab. The overall 30 day mortality rate across the whole cohort of patients during this period was 3% (n = 3). Of those testing positive for SARS-CoV-2 66% (n = 6) developed significant COVID-19 related complications and there was a 33% 30-day mortality rate (n = 3). Overall, the 30-day mortality in patients classified as BOA low or medium risk (n = 69) was 0%, whereas in those classified as high or very high risk (n = 27) it was 11.1%. CONCLUSION: Orthopaedic surgery in SARS-CoV-2 negative patients who transition to positive within 30 days of surgery carries a significant risk of morbidity and mortality. In lower risk groups, the overall risk of becoming SARS-CoV-2 positive, and subsequently developing a significant postoperative related complication, was low even during the peak of the pandemic. In addition to ensuring patients are SARS-CoV-2 negative at the time of surgery it is important that the risk of acquiring SARS-CoV-2 is minimized through their recovery.Cite this article: Bone Joint Open 2020;1-8:474-480.

Threshold for Computer- and Robot-Assisted Knee and Hip Replacements in the English National Health Service.

OBJECTIVES: To estimate threshold prices for computer- and robot-assisted knee and hip replacement. METHODS: A lifetime cohort Markov model provided the framework for analysis. Linked primary care and inpatient hospital records informed estimates of outcomes under current practice. Outcomes were estimated under a range of hypothetical relative improvements in quality of life if unrevised and in revision risk after computer or robot-assisted surgery. Threshold prices, a price at which the net health benefit from funding the intervention would be zero, for these improvements were estimated for a cost-effectiveness threshold of £20 000 per additional quality-adjusted life-year (QALY) gained. RESULTS: For average patient profiles under current knee and hip replacement practice, lifetime QALYs were 10.3 (9.9 to 10.7) and 11.0 (10.6 to 11.4), with costs of £6060 (£5947 to £6203) and £6506 (£6335 to £6710) for knee and hip replacement, respectively. A combined 50% relative reduction in risk of revision and 5% improvement in postoperative quality of life if unrevised would, for example, result in QALYs increasing to 10.9 (10.4 to 11.3) and 11.6 (11.2 to 12.0), and costs falling to £5880 (£5816 to £5956) and £6258 (£6149 to £6376) after knee and hip replacement, respectively. These particular improvements would have an associated threshold price of £11 182 (£10 691 to £11 721) for knee replacement and £12 134 (£11 616 to £12 701) for hip replacement. The 50% reduction in revision rate alone would have associated threshold prices of £1094 (£788 to £1488) and £1347 (£961 to £1842), and the 5% improvement in quality of life alone would have associated threshold prices of £9911 (£9476 to £10 296) and £10 578 (£10 171 to £10 982). CONCLUSIONS: At current prices, computer- and robot-assisted knee and hip replacement will likely need to lead to improvements in patient-reported outcomes in addition to any reduction in the risk revision.

Candidacy for medial unicompartmental knee replacement declines with age.

BACKGROUND: The effect of age on the percentage of primary knee replacements appropriate for unicompartmental replacement (UKR), defined as candidacy, is unknown. The aim was to determine the candidacy and outcome of UKR in different age groups. HYPOTHESIS: Age is associated with candidacy for medial UKR. PATIENTS AND METHODS: This cross-sectional study determined UKR candidacy from preoperative radiographs, including stress views, from 457 consecutive knee replacements (TKR or UKR) in a specialist joint replacement centre. Candidacy, estimated from radiographs and from usage, was determined for all knees and then stratified by age group<50, 50-60, 60-70, 70-80, and 80+. The outcome of UKR implanted in these groups was also assessed. To avoid overestimating, candidacy estimated by usage was used for the primary analysis. RESULTS: Candidacy decreased with age (OR 0.98, p=0.008) and was 61% (CI 42-78), 52% (CI 43-61), 43% (CI 35-51), 41% (CI 31-52), and 36% (CI 22-52) respectively. Candidacy estimated by radiographs was slightly higher overall (49% compared to 46%) and in all age groups than candidacy estimated from usage. Neither functional outcome (p=0.47) nor implant survival (p=0.54) was affected by age. Overall 80% achieved good/excellent Knee Society objective scores, and the five-year implant survival was 99%. DISCUSSION: There is a strong association of candidacy for UKR with age in that younger patients are more likely to be candidates (61% in those<50 and 36% in those 80+). Good outcomes can be expected in patients of all ages who are appropriate for UKR. LEVEL OF EVIDENCE: IV, Prognostic cross-sectional study.

Study of Peri-Articular Anaesthetic for Replacement of the Knee (SPAARK): study protocol for a patient-blinded, randomised controlled superiority trial of liposomal bupivacaine.

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.

Is Knee Joint Distraction a Viable Treatment Option for Knee OA?-A Literature Review and Meta-Analysis.

Knee joint distraction (KJD) is a new application of an established technique to regenerate native cartilage using an external fixator. The purpose of this study is to perform a systematic review and meta-analysis of the literature to determine whether KJD is beneficial for knee osteoarthritis and how results compare with established treatments. Studies assessing the outcomes of KJD were retrieved, with three studies (one cohort and two randomized controlled trials), 62 knees, meeting the inclusion criteria. The primary outcome was functional outcome, assessed using a validated outcome score, at 1 year. Secondary outcomes included pain scores, structural assessment of the joint, and adverse events. KJD is associated with improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from baseline to 1 year as well as reductions in pain scores and improvements in structural parameters assessed radiographically and by magnetic resonance imaging. KJD is not associated with decreased knee flexion, but is associated with a high risk of pin site infection. In patients aged 65 years or under at 1 year, no differences in WOMAC or pain scores was detected between patients managed with KJD compared with high tibial osteotomy or total knee arthroplasty. KJD may represent a potential treatment for knee arthritis, though further trials with longer term follow-up are required to establish its efficacy compared with contemporary treatments. This is a Level I (systematic review and meta-analysis) study.

Health Care Professionals' Perceptions of the Arthroplasty Patient Experience: Planning Phase in the Development of a Patient-Reported Outcome Measure.

PURPOSE: The aim of this study was to explore health care professionals' perceptions and perspectives of surgery and early recovery for patients undergoing lower limb arthroplasty. DESIGN: Thematic analysis with semi-structured qualitative interviews. METHODS: Following ethical approval, interviews were performed with recovery room nurses (n=3), ward nurses (n=2), surgeons (n=5), anesthesiologists (n=5), physiotherapists (n=5), and occupational therapists (n=2). Data were analyzed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. FINDINGS: Three main themes evolved from the interviews: immediate patient recovery issues, discharge criteria, and priorities during hospitalization from health care providers' perspectives. CONCLUSIONS: The early postoperative recovery period can be a challenging time for health care providers and patients alike. However, identifying key areas of importance can provide insight and guide focus in clinical practice, thus improving patient recovery.

Upper tibial MRI vascular marks lost in early knee osteoarthritis.

BACKGROUND: We describe upper tibial radiating vascular marks on MRI scans. They are lost in early osteoarthritis (OA). METHODS: A literature search revealed no previous description of upper tibial MRI radial vascular marks. Fifty-six consecutive patients with anteroposterior knee X-rays and an axial PD_SPAIR MRI scan of the same knee within 1 year were studied. Their mean age was 53.1 years (range 22-85) with 27 males and 29 females. The medial and lateral compartments of each knee were scored for osteoarthritis using the Kellgren-Lawrence (K-L) classification. Marks on the MRI scans were counted by layer and quadrant position. RESULTS: Radial vascular marks were present in the first axial upper tibial subchondral slice, peaked between 6 and 10 mm depth and were absent by 16 mm depth. There was no association with age, left or right knee, BMI, or weight. There was more K-L graded OA medially and more vascular marks laterally. There was an inverse correlation between the number of marks and early grades of osteoarthritis medially (p < 0.001) and laterally (p < 0.002). CONCLUSION: We demonstrate previously undescribed subchondral vascular marks on axial MRI scans of the tibia and their inverse correlation with the presence and severity of early knee osteoarthritis. Our work offers a new insight into the possible vascular aetiology of osteoarthritis and potentially a means of earlier diagnosis and a therapeutic target.

Age and Outcomes of Medial Meniscal-Bearing Unicompartmental Knee Arthroplasty.

BACKGROUND: National joint registries report increasing revision rates with decreasing patient age for all types of joint arthroplasty. This study aimed to explore the effect of age on function and revision risk in patients undergoing medial meniscal-bearing UKA. METHODS: A prospectively followed cohort of 1000 consecutive medial meniscal-bearing UKAs at a designer center was analyzed. All knees were implanted for recommended indications and had mean 10-year follow-up. Patients were grouped by age at surgery (<55, 55 to <65, 65 to <75, 75+). Oxford Knee Scores (OKS) were assessed at 5 and 10 years. Component-time revision incidence rates and Kaplan-Meier implant survival were calculated. RESULTS: Mean patient age at surgery was 66.6 years (range, 33-88). All age-groups had significant (P < .001) improvement in OKS over time, and at 5 years achieved a median OKS of 44. At 10 years, median OKS, from youngest group to eldest, were 44, 45, 42, and 39, with the eldest group having a significantly lower OKS (P < .01). Ten-year implant survival rates were 97%, 94%, 94%, and 93%, respectively, and was not significantly associated with age at UKA. CONCLUSION: Medial meniscal-bearing UKA provides good functional outcomes in all age-groups; however, in older patients (75+), the functional outcome deteriorated at 10 years presumably due to deteriorating health. Contrary to registry observations, the revision rate was not higher in younger patients. These results suggest that, with correct indications, patient age should not be considered a contraindication to medial meniscal-bearing UKA.

Cost-effectiveness of unicompartmental compared with total knee replacement: a population-based study using data from the National Joint Registry for England and Wales.

OBJECTIVES: To assess the value for money of unicompartmental knee replacement (UKR) compared with total knee replacement (TKR). DESIGN: A lifetime Markov model provided the framework for the analysis. SETTING: Data from the National Joint Registry (NJR) for England and Wales primarily informed the analysis. PARTICIPANTS: Propensity score matched patients in the NJR who received either a UKR or TKR. INTERVENTIONS: UKR is a less invasive alternative to TKR, where only the compartment affected by osteoarthritis is replaced. PRIMARY OUTCOME MEASURES: Incremental quality-adjusted life years (QALYs) and healthcare system costs. RESULTS: The provision of UKR is expected to lead to a gain in QALYs compared with TKR for all age and gender subgroups (male: <60 years: 0.12, 60-75 years: 0.20, 75+ years: 0.19; female: <60 years: 0.10, 60-75 years: 0.28, 75+ years: 0.44) and a reduction in costs (male: <60: £-1223, 60-75 years: £-1355, 75+ years: £-2005; female: <60 years: £-601, 60-75 years: £-935, 75+ years: £-1102 per patient over the lifetime). UKR is expected to lead to a reduction in QALYs compared with TKR when performed by surgeons with low UKR utilisation but an increase among those with high utilisation (<10%, median 6%: -0.04, ≥10%, median 27%: 0.26). Regardless of surgeon usage, costs associated with UKR are expected to be lower than those of TKR (<10%: £-127, ≥10%: £-758). CONCLUSIONS: UKR can be expected to generate better health outcomes and lower lifetime costs than TKR. Surgeon usage of UKR does, however, have a significant impact on the cost-effectiveness of the procedure. To achieve the best results, surgeons need to perform a sufficient proportion of knee replacements as UKR. Low usage surgeons may therefore need to broaden their indications for UKR.

Ten-year patient-reported outcomes following total and minimally invasive unicompartmental knee arthroplasty: a propensity score-matched cohort analysis.

PURPOSE: For patients with medial compartment arthritis who have failed non-operative treatment, either a total knee arthroplasty (TKA) or a unicompartmental knee arthroplasty (UKA) can be undertaken. This analysis considers how the choice between UKA and TKA affects long-term patient-reported outcome measures (PROMs). METHODS: The Knee Arthroplasty Trial (KAT) and a cohort of patients who received a minimally invasive UKA provided data. Propensity score matching was used to identify comparable patients. Oxford Knee Score (OKS), its pain and function components, and the EuroQol 5 Domain (EQ-5D) index, estimated on the basis of OKS responses, were then compared over 10 years following surgery. Mixed-effects regressions for repeated measures were used to estimate the effect of patient characteristics and type of surgery on PROMs. RESULTS: Five-hundred and ninety UKAs were matched to the same number of TKAs. Receiving UKA rather than TKA was found to be associated with better scores for OKS, including both its pain and function components, and EQ-5D, with the differences expected to grow over time. UKA was also associated with an increased likelihood of patients achieving a successful outcome, with an increased chance of attaining minimally clinically important improvements in both OKS and EQ-5D, and an 'excellent' OKS. In addition, for both procedures, patients aged between 60 and 70 and better pre-operative scores were associated with better post-operative outcomes. CONCLUSION: Minimally invasive UKAs performed on patients with the appropriate indications led to better patient-reported pain and function scores than TKAs performed on comparable patients. UKA can lead to better long-term quality of life than TKA and this should be considered alongside risk of revision when choosing between the procedures. LEVEL OF EVIDENCE: II.

Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient-reported outcome measure.

AIMS AND OBJECTIVES: To explore the patients' perspective of surgery and early recovery when undergoing lower limb (hip or knee) arthroplasty. BACKGROUND: Lower limb arthroplasty is a commonly performed procedure for symptomatic arthritis, which has not responded to conservative medical treatment. Each patient's perspective of the surgical process and early recovery period impacts on their quality of life. DESIGN: Open, semistructured qualitative interviews were used to allow for a deeper understanding of the patient perspective when undergoing a hip or knee arthroplasty. METHODS: Following ethical approval, 30 patients were interviewed between August and November 2016 during the perioperative period while undergoing an elective hip or knee arthroplasty (n = 30). The interviews were performed between the day of surgery and a nine-week postoperative clinic appointment. Data were analysed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. RESULTS: Seven main themes evolved from the interviews: "improving function and mobility", "pain", "experiences of health care", "support from others", "involvement and understanding of care decisions", "behaviour and coping" and "fatigue and sleeping". CONCLUSIONS: The early postoperative recovery period is of vital importance to all surgical patients. This is no different for the orthopaedic patient. However, identifying key self-reported areas of importance from patients can guide clinical focus for healthcare professionals. RELEVANCE TO CLINICAL PRACTICE: To have specific patient-reported information regarding key areas of importance during the perioperative phase is invaluable when caring for the orthopaedic surgical patient. It gives insight and understanding in to this increasing population group. This study has also served as a starting point in the development of a questionnaire which could be used to assess interventions in the lower limb arthroplasty population. These results will influence both items and content of the questionnaire.

Long-term outcomes of over 8,000 medial Oxford Phase 3 Unicompartmental Knees-a systematic review.

Background and purpose - There is debate as to the relative merits of unicompartmental and total knee arthroplasty (UKA, TKA). Although the designer surgeons have achieved good results with the Oxford UKA there is concern over the reproducibility of these outcomes. Therefore, we evaluated published long-term outcomes of the Oxford Phase 3 UKA. Patients and methods - We searched databases to identify studies reporting ≥10 year outcomes of the medial Oxford Phase 3 UKA. Revision, non-revision, and re-operation rates were calculated per 100 component years (% pa). Results - 15 studies with 8,658 knees were included. The annual revision rate was 0.74% pa (95% CI 0.67-0.81, n = 8,406) corresponding to a 10-year survival of 93% and 15-year survival of 89%. The non-revision re-operation rate was 0.19% pa (95% CI 0.13-0.25, n = 3,482). The re-operation rate was 0.89% pa (95% CI 0.77-1.02, n = 3,482). The most common causes of revision were lateral disease progression (1.42%), aseptic loosening (1.25%), bearing dislocation (0.58%), and pain (0.57%) (n = 8,658). Average OKS scores were 40 at 10 years (n = 3,417). The incidence of medical complications was 0.83% (n = 1,443). Interpretation - Very good outcomes were achieved by both designer and non-designer surgeons. The PROMs, medical complication rate, and non-revision re-operation rate were better than those found in meta-analyses and publications for TKA but the revision rate was higher. However, if failure is considered to be all re-operations and not just revisions, then the failure rate of UKA was less than that of TKA.

Perioperative adjuvant corticosteroids for postoperative analgesia in knee arthroplasty.

Background and purpose - Immediate postoperative pain management offered in knee arthroplasty is suboptimal in up to one-third of patients resulting in high opiate consumption and delayed discharge. In this meta-analysis we investigate the analgesic effect and safety of perioperative adjuvant corticosteroids in knee arthroplasty. Methods - Databases Medline, Embase, and Central were searched for randomized studies comparing the analgesic effect of adjuvant perioperative corticosteroids in knee arthroplasty. Our primary outcome was pain score at 24 hours postoperatively. Secondary outcomes included pain at 12, 48, and 72 hours, opiate consumption, postoperative nausea and vomiting, infection, and discharge time. Systemic (intravenous) and local (intra-articular) corticosteroids were analyzed separately. Results - 14 randomized controlled trials (1,396 knees) were included. Mean corticosteroid dosages were predominantly 50-75mg oral prednisolone equivalents for both systemic and local routes. Systemic corticosteroids demonstrated statistically significant and clinically modest reductions in pain at 12 hours by -1.1 points (95%CI -2.2 to 0.02), 24 hours by -1.3 points (CI -2.3 to -0.26) and 48 hours by -0.4 points (CI -0.67 to -0.04). Local corticosteroids did not reduce pain. Opiate consumption, postoperative nausea and vomiting, infection, or time till discharge were similar between groups. Interpretation - Corticosteroids modestly reduce pain postoperatively at 12 and 24 hours when used systemically without any increase in associated risks for dosages between 50 and 75 mg oral prednisolone equivalents.