Implementation of a day-stay joint replacement pathway in an Australian regional public hospital: A descriptive study.

OBJECTIVE: To describe the implementation, feasibility and safety of a day-stay joint replacement pathway in a regional public hospital in Australia. METHOD: Over a 12-month pilot period, a prospective descriptive analysis of consecutive patients undergoing total knee and hip arthroplasty was conducted. The number of eligible day-stay patients, proportion of successful same-day discharges and reasons for same-day failure to discharge were recorded. Outcome measures captured for all joint replacements across this period included length of stay (LoS), patient reported outcomes, complications and patient satisfaction. The implementation pathway as well as patient and staff identified success factors derived from interviews were outlined. RESULTS: Forty-one/246 (17%) patients booked for joint replacement surgery were eligible for day-stay and 21/41 (51%) achieved a successful same-day discharge. Unsuccessful same-day discharges were due to time of surgery too late in the day (7/20), no longer meeting same-day discharge criteria (11/20) and declined discharge same-day (2/20). Over the implementation period 65% (162/246) of all patients were discharged with a LoS of 2 days or less. Patient satisfaction for the day-stay pathway was high. Complication rates and patient-reported outcomes were equivalent across LoS groups. CONCLUSION: The day-stay joint replacement surgery pathway was feasible to implement, safe and acceptable to patients. Day-stay pathways have potential patient and system-level efficiency benefits.

Applying models of care for total hip and knee arthroplasty: External validation of a published predictive model to identify extended stay risk prior to lower-limb arthroplasty.

OBJECTIVE: This study aimed to externally validate a reported model for identifying patients requiring extended stay following lower limb arthroplasty in a new setting. DESIGN: External validation of a previously reported prognostic model, using retrospective data. SETTING: Medium-sized hospital orthopaedic department, Australia. PARTICIPANTS: Electronic medical records were accessed for data collection between Sep-2019 and Feb-2020 and retrospective data extracted from 200 randomly selected total hip or knee arthroplasty patients. INTERVENTION: Participants received total hip or knee replacement between 2-Feb-16 and 4-Apr-19. This study was a non-interventional retrospective study. MAIN MEASURES: Model validation was assessed with discrimination, calibration on both original and adjusted forms of the candidate model. Decision curve analysis was conducted on the outputs of the adjusted model to determine net benefit at a predetermined decision threshold (0.5). RESULTS: The original model performed poorly, grossly overestimating length of stay with mean calibration of -3.6 (95% confidence interval -3.9 to -3.2) and calibration slope of 0.52. Performance improved following adjustment of the model intercept and model coefficients (mean calibration 0.48, 95% confidence interval 0.16 to 0.80 and slope of 1.0), but remained poorly calibrated at low and medium risk threshold and net benefit was modest (three additional patients per hundred identified as at-risk) at the a-priori risk threshold. CONCLUSIONS: External validation demonstrated poor performance when applied to a new patient population and would provide limited benefit for our institution. Implementation of predictive models for arthroplasty should include practical assessment of discrimination, calibration and net benefit at a clinically acceptable threshold.

Imageless navigation system (Naviswiss) provides accurate component position in total hip arthroplasty with lateral decubitus position for end-stage hip osteoarthritis: a prospective cohort study with CT-validation.

AIMS: The Naviswiss system (Naviswiss AG, Brugg, Switzerland) is a handheld imageless navigation device used to improve the accuracy of implant positioning in total hip arthroplasty (THA). However, clinical data for leg length discrepancy and femoral offset is lacking, and the validity of the system has not been reported for patients undergoing THA in the lateral decubitus position. This study aimed to report the accuracy of the device in this patient population. METHODS: Patients underwent THA in the lateral decubitus position performed by a single surgeon. Component position measured by the device intraoperatively was compared to postoperative measurements on computed tomography (CT) scans. Agreement between the navigation system and postoperative measurements was reported for acetabular cup inclination, acetabular cup version, femoral offset, and leg length discrepancy. RESULTS: Thirty-three patients were included in the analysis. The mean difference between intraoperative and postoperative CT measurements was within 2° for angular measurements and 2 mm for leg length. Absolute differences in the two indices were up to 4° and 3 mm. The mean bias was 1°-2° overestimation for cup orientation and up to 2 mm overestimation for leg length change. However, 95% limits of agreement did not exceed absolute thresholds of 10° and 10 mm, especially after correction for bias. One case (3%) was declared intraoperatively for issues with fixation on the greater trochanter. CONCLUSIONS: The accuracy of the Naviswiss system falls within clinically acceptable recommendations for acetabular cup placement, femoral offset, and leg length for total hip arthroplasty with a anterolateral approach in lateral decubitus position. The system could be further improved with regression-based bias correction.

A physiotherapy-led review of guideline-based care for community-dwelling older people presenting to a metropolitan hospital with accidental falls.

OBJECTIVE(S): Several guidelines exist to inform best-practice management of community-dwelling fallers. This study aimed to outline a pragmatic approach to developing an audit tool for guideline-based care of falls and provide an overview of current practice. METHODS: An audit tool to determine compliance with guideline-based care was developed with an allied health and physiotherapy focus, utilising the Australian Commission on Safety and Quality in Health-Care Guidelines for Preventing Falls and Harm from Falls in Older People (2009) and Queensland State Government 'Stay on your Feet' guidelines. A retrospective audit of medical records was completed in July 2020 of community-dwelling people aged 65 years and over with a fall-related emergency department (ED) presentation in a medium-sized metropolitan hospital in Australia. Data were compared between patients admitted to hospital and those discharged home from the ED. RESULTS: Ninety-three patients were included: 68 were discharged home from ED and 25 were admitted to hospital. There was a significant difference in receiving an allied health review (p < .001) between admitted patients (96%) and those who discharged home from ED (68%). The Clinical Frailty Scale was only completed for 23% of patients. Physiotherapy quality-of-care (n = 46 patients) was variable, with poor completion of physical outcome measures (7%) and fall education (4%). However, assessment of mobility was routinely completed (94%), and most patients were referred to an appropriate community service (66%). CONCLUSIONS: Adherence to guideline-based care of community-dwelling fallers is inconsistent. Improvements are required in the consistency of risk stratification, comprehensive physical assessment and patient education.

CT validation of intraoperative imageless navigation (Naviswiss) for component positioning accuracy in primary total hip arthroplasty in supine patient position: a prospective observational cohort study in a single-surgeon practice.

BACKGROUND: The aim of this study was to report on the validity of the Naviswiss handheld image-free navigation device for accurate intraoperative measurement of THA component positioning, in comparison with the three-dimensional (3D) reconstruction of computed tomography (CT) images as the gold standard. METHODS: A series of patients presenting to a single-surgeon clinic with end-stage hip osteoarthritis received primary hip arthroplasty with the anterolateral muscle-sparing surgical approach in the supine position. Imageless navigation was applied during the procedure with bone-mounted trackers applied to the greater trochanter and ASIS. Patients underwent routine CT scans before and after surgery and these were analyzed by using three-dimensional reconstruction to generate cup orientation, offset and leg length changes, which were compared to the intraoperative measurements provided by the navigation system. Estimates of agreement between the intraoperative and image-derived measurements were assessed with and without correction for bias and declared cases with potential measurement issues. RESULTS: The mean difference between intraoperative and postoperative CT measurements was within 2° for angular measurements and 2 mm for leg length. Absolute differences for the two indices were between 5° and 4 mm. Mean bias was 1.9°-3.6° underestimation for cup orientation and up to 2 mm overestimation for leg length change, but absolute thresholds of 10° and 10 mm were not exceeded by 95% limits of agreement (LOA), especially after correction for bias. Four cases (12%) were declared intraoperatively for issues with fixation on the greater trochanter. Inclusion of these cases generated acceptable accuracy overall and their omission failed to improve between-case variability in accuracy or LOA for both offset and leg length. CONCLUSIONS: The accuracy of the Naviswiss system applied during primary THA in a supine position and anterolateral surgical approach falls within clinically acceptable recommendations for acetabular cup placement, femoral offset, and length. With refinements to surgical technique to adapt to the navigation hardware, the system could be further improved with regression-based bias correction. TRIAL REGISTRATION: Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618000317291).

Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Knee extension deficits complicate recovery from ACL injury and reconstruction; however, the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence. METHODS: A systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta-analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a nonzero incidence and (ii) the relationship between the predictors and nonzero LOE incidence. RESULTS: A sample of 15,494 studies were retrieved using the search criteria, with 53 studies meeting eligibility criteria. The pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow-up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on nonzero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12 month follow-up, reducing to 1 in 4 at 2 years. CONCLUSIONS: This review examined the definitions for the measurement and interpretation of postoperative knee extension and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits was difficult to infer due to discrepancies in measurement techniques and patient variation. On average, 1 in 3 patients may present with loss of extension of at least 3 degrees at 12-month follow-up, decreasing to 1 in 4 at 2 years. These results may be used by clinicians as an upper threshold for acceptable complication rates following ACLR. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history. PROSPERO REGISTRATION NUMBER: CRD42018092295. LEVEL OF EVIDENCE: Level I.

Early Clinical Outcomes and Complications of Transfibular Total Ankle Arthroplasty: The Australian Experience.

BACKGROUND: We report the short-term outcomes of a retrospective cohort of Trabecular Metal total ankle arthroplasties (TAAs) via a transfibular approach from a single, nondesigner surgeon in Australia. METHODS: This was a retrospective cohort study. Demographic, clinical, and patient-reported outcome measures (PROMs) were collected. The primary outcome was the Foot and Ankle Outcome Score (FAOS), and secondary outcomes included patient satisfaction, the EuroQol-5 Dimension (EQ5D), and complications including revision rates. RESULTS: Between 2016 and 2019, 84 trabecular metal prostheses were implanted in 84 patients. Mean age (SD) at time of surgery was 68 (7.8) years, and 46 (55%) were male. Mean follow-up (SD) was 26.1 (13) months. There were significant (P < .001) improvements in the FAOS in the subscales of pain (47.9 to 79.1), activities of daily living (59.5 to 83.7), and quality of life (25.5 to 60.2) and EQ-5D (0.55 to 0.75) (P < .001), and overall satisfaction was 69.6%. The commonest complications were wound infection or breakdown (11.9%, n=10), fibular nonunion (3.5%), plate irritation (3.5%), and tibial nerve neuropathy (3.5%). There were no thromboembolic complications. Implant survivorship was 100%, with Trabecular Metal components retained in all patients. Two patients developed deep infection, with 1 requiring debridement and polyethylene exchange. No patients experienced implant loosening. CONCLUSION: Our results demonstrate that the trabecular metal survival rates are comparable with other total ankle implants in the Australian Orthopaedic Association National Joint Replacement Registry and as published in other international literature. Overall patient satisfaction was high, as were PROMs. However, the data highlight potential complications uniquely associated with this implant. The authors believe that these figures support TAA via a transfibular approach as a viable option in the treatment of ankle arthritis. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Agreement between the American Shoulder and Elbow Surgeons Society Standardized Shoulder Assessment score (ASES) and the Oxford Shoulder Score (OSS) in patients presenting with shoulder pathology: A cohort analysis of the Clinical Quality Registry for Outcomes in Shoulder and Elbow Pathology (CROSEP) registry.

Background: The choice of patient-reported outcome measure (PROM) used in shoulder studies varies based on clinician's preference and location. This creates difficulties when attempting to compare studies which have used different PROMs as their outcome measure. This study aims to assess the agreement between the American Shoulder and Elbow Surgeons score (ASES) and the Oxford Shoulder Score (OSS), and identify factors associated with agreement. Methods: Patients with shoulder pathology were identified from a multi-cohort observational practice registry. 1050 paired ASES and OSS pre-treatment scores were prospectively collected. Linear regression was performed to assess the agreement between the PROMs. Mixed-effects analysis of variance was performed to assess the influence of factors associated with agreement. Results: Regression for mean total and mean function ASES and OSS demonstrated good fit (adjusted R2 57.7%, P < 0.001; and 63.9%, P < 0.001). Mean pain subscore demonstrated a poorer fit (adjusted R2 39.4%, P < 0.001). Crosswalks to convert between mean scores were produced with reasonable precision. Veterans RAND 12-Item Health Survey score, age and diagnosis cohort influenced agreement. Conclusion: Mean total and mean function ASES and OSS scores agree well with each other. This allows for a more informed comparison of studies using either PROMs as their outcome measure.

The effect of osteotomy technique (flat-cut vs wedge-cut Weil) on pain relief and complication incidence following surgical treatment for metatarsalgia in a private metropolitan clinic: protocol for a randomised controlled trial.

BACKGROUND: Weil osteotomies are performed to surgically treat metatarsalgia, by shortening the metatarsal via either a single distal oblique cut with translation of the metatarsal head (flat-cut) or through the removal of a slice of bone (wedge-cut). The wedge-cut technique purportedly has functional and mechanical advantages over the flat-cut procedure; however, in vivo data and quality of evidence are currently lacking. This study aims to investigate whether wedge-cut Weil osteotomy compared to traditional flat-cut Weil is associated with increased pain relief and fewer complications up to 12 months postoperatively. METHODS: Patient, surgical and clinical data will be collected for 80 consecutive consenting patients electing to undergo surgical treatment of propulsive metatarsalgia in a randomised control trial, embedded within a clinical registry. The primary outcome is patient-reported pain as assessed by the Foot and Ankle Outcome Score (FAOS) - Pain subscale, and the secondary outcome is the incidence of procedure-specific complications at up to 12 months postoperatively. The groups will be randomised using a central computer-based simple randomisation system, with a 1:1 allocation without blocking and allocation concealment. A mixed-effects analysis of covariance will be used to assess the primary outcome, with confounders factored into the model. A binary logistic regression will be used to assess the secondary outcome in a multivariable model containing the same confounders. DISCUSSION: To the best of the authors' knowledge, the trial will be the first to examine the clinical efficacy of the wedge-cut Weil osteotomy compared to the flat-cut technique with a prospective, randomised control design. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620001251910. Registered on 23 November 2020.

Patient-reported outcomes of a short hospital stay after total knee replacement in a regional public hospital: a prospective cohort treated 2018-2019.

BACKGROUND: Patient-reported outcomes and satisfaction following short length of stay (LoS) after total knee arthroplasty (TKA) in the Australian regional context remain unexplored. This study reports complications, outcomes and satisfaction of patients discharged from an enhanced recovery protocol (ERP), 6 weeks after TKA in a regional hospital. METHODS: Prospective recruitment occurred between 2018 and 2019. Demographics, intraoperative data, complications and emergency department (ED) presentations were retrieved from hospital records. Complications were graded for severity using a published scale. Knee range of motion (ROM), timed up-and-go (TUG), 6-min walk test (6MWT) and Oxford Knee Scores (OKS) were assessed preoperatively and 6 weeks postoperatively. Patient satisfaction was assessed via questionnaire at the postoperative follow-up. RESULTS: One hundred patients/117 primary TKAs were prospectively included. Median LoS was 2 days (interquartile range 1-3 days) with 74.4% and 88.4% of patients satisfied with their knee and LoS, at 6 weeks respectively. Twenty-seven patients presented to the ED a total of 37 times with complication severity of Grade III or less, and 10 patients were readmitted. Significant improvements in objective and subjective outcomes were observed, however only change in median OKS exceeded the minimal clinically important difference (MCID) threshold. CONCLUSION: An enhanced recovery protocol after TKA in a regional hospital can achieve a median LoS of 2 days without compromising patient-reported outcomes and objective functional measures, whilst maintaining a high level of patient satisfaction with both the surgery and LoS. Further work is required to better optimize management of largely low-grade complications in this patient population.

Baseline Analysis of Patients Presenting for Surgical Review of Anterior Cruciate Ligament Rupture Reveals Heterogeneity in Patient-Reported Outcome Measures.

Despite the establishment of successful surgical techniques and rehabilitation protocols for anterior cruciate ligament (ACL) reconstruction, published return to sport rates are less than satisfactory. This has led orthopaedic surgeons and researchers to develop more robust patient selection methods, and investigate prognostic patient characteristics. No previous studies have integrated baseline characteristics and responses to patient-reported outcome measures (PROMs) of patients with ACL rupture presenting for surgical review. Patients electing to undergo ACL reconstruction under the care of a single orthopaedic surgeon at a metropolitan public hospital were enrolled in a clinical quality registry. Patients completed Veterans RAND 12-item Health Survey (VR-12) Physical Component Summary and Mental Component Summary scores, Tegner activity scale, and International Knee Documentation Committee (IKDC) questionnaires at presentation. Total scores were extracted from the electronic registry, and a machine learning approach (k-means) was used to identify subgroups based on similarity of questionnaire responses. The average scores in each cluster were compared using analysis of variance (ANOVA; Kruskal-Wallis) and nominal logistic regression was performed to determine relationships between cluster membership and patient age, gender, body mass index (BMI), and injury-to-examination delay. A sample of 107 patients with primary ACL rupture were extracted, with 97 (91%) available for analysis with complete datasets. Four clusters were identified with distinct patterns of PROMs responses. These ranged from lowest (Cluster 1) to highest scores for VR-12 and IKDC (Cluster 4). In particular, Cluster 4 returned median scores within 6 points of the patient acceptable symptom state for the IKDC score for ACL reconstruction (70.1, interquartile range: 59-78). Significant (p < 0.05) differences in PROMs between clusters were observed using ANOVA, with variance explained ranging from 40 to 69%. However, cluster membership was not significantly associated with patient age, gender, BMI, or injury-to-examination delay. Patients electing to undergo ACL reconstruction do not conform to a homogenous group but represent a spectrum of knee function, general physical and mental health, and preinjury activity levels, which may not lend itself to uniform treatment and rehabilitation protocols. The factors driving these distinct responses to PROMs remain unknown but are unrelated to common demographic variables.

Minimally Invasive Inlay Prosthesis Unicompartmental Knee Arthroplasty for the Treatment of Unicompartmental Osteoarthritis: A Prospective Observational Cohort Study with Minimum 2-Year Outcomes and up to 14-Year Survival.

There are limited medium-term outcome data available for the Repicci II device in unicompartmental knee arthroplasty (UKA). The purpose of this study was to report the medium-term (minimum 2 years) patient-reported outcomes and long-term (up to 14 years) procedure survival in a consecutive series of patients undergoing an inlay prosthesis UKA (Repicci II) at an independent orthopaedic clinic. Patients presenting with medially localized unicompartmental knee osteoarthritis and meeting the criteria appropriate for UKA were recruited to a clinical patient registry at the time of presentation. A cemented unicompartmental prosthesis (Repicci II) was implanted using minimally invasive techniques with rapid postoperative mobilization. Patients were asked to complete patient-reported outcomes preoperatively and annually postoperatively. A procedure list was cross-matched with the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and an analysis of procedure survival was performed with comparison to the national data for UKA. Data from a cohort of 661 primary medial compartment UKA procedures performed in 551 patients over a 15-year period were extracted from the clinical patient registry. Significant improvements were maintained in general health, disease symptoms, pain, and function at an average follow-up of 9 years compared with preoperative data. Threshold analysis revealed that >65% of patients exceeded Patient Acceptable Symptom State at the latest follow-up, with >80% within or exceeding age-matched norms for general health. Cumulative revision rate was significantly lower than that reported for UKA in the AOANJRR at up to 13 years follow-up. This series represents a lower cumulative revision rate than previously reported, with >65% of patients reporting satisfactory functional outcomes at an average of 9 years from surgery. Surgical options for treating unicompartmental knee osteoarthritis could include UKA as a viable alternative; however, clear definitions of procedure success and its overall cost-benefit ratio in the context of ongoing management of knee osteoarthritis remain to be elucidated.

Factors Affecting Hospital Length of Stay following Total Knee Replacement: A Retrospective Analysis in a Regional Hospital.

In an effort to reduce hospital length of stay (LoS) following total knee arthroplasty (TKA), patient management strategies have evolved over time. The aims of this study were threefold: first, to quantify the reduction in LoS for TKA in a regional hospital; second, to identify the patient, surgical and management factors associated with hospital LoS; and lastly, to assess the change in complications incidence and hospital readmission as a function of LoS. A retrospective chart review was conducted on a consecutive series of primary and revision TKAs from January 2012 to March 2018. Factors describing patient demographics, as well as preoperative, intraoperative, surgical, and postoperative management, were extracted from paper and electronic medical records by a team of reviewers. Multivariate linear regression was performed to assess the association between these factors and LoS. In total, 362 procedures were included, which were reduced to 329 admissions once simultaneous bilateral procedures were taken into account. Median LoS reduced significantly (p = 0.001) from 6 to 2 days over the period of review. A stepwise regression analysis identified patient characteristics (age, gender, comorbidities, discharge barriers), perioperative management (anesthesia type), surgical characteristics (approach, alignment method), and postoperative management (mobilization timing, postoperative narcotic use, complication prior to discharge) as factors explaining 58.3% of the variance in LoS. Representation to emergency (6%) and hospital readmission (3%) remained low for the reviewed period. Efforts to reduce hospital LoS following TKA within a regional hospital setting can be achieved over time without significant increases in the rate or severity of complications or representation to acute care and subsequent readmission. The findings establish the role of patient, surgical and management factors in the context of agreed discharge criteria between care providers.

Evolution of service metrics and utilisation of objective discharge criteria in anterior cruciate ligament reconstruction rehabilitation: a retrospective cohort study with historical control in a public hospital physiotherapy department.

BACKGROUND: ACL reconstruction (ACLR) is a common procedure requiring rehabilitation in public hospital physiotherapy departments. The rate of re-rupture and reduced rates of return to sport following ACLR are concerning. Current guidelines recommend a progressive approach to rehabilitation based on objective criteria. The aim of this study was to determine whether a new public hospital model of care incorporating a phase-based program increased physiotherapist utilisation of objective outcome measures, improved service metrics including attendance and rehabilitation completion rates, and increased patient-reported activity and knee function. METHODS: Records from patients attending outpatient physiotherapy after ACL reconstruction (N = 132) were included in a retrospective chart review to assess utilisation of objective measures such as quadricep and hamstring strength assessment, patient attendance and rehabilitation completion. Phone followup (minimum 1 year) was conducted to retrieve patient-reported measures of knee function (IKDC) and activity (Tegner Activity Scale). Patients were categorised by rehabilitation model of care (contemporary - time based [N = 93] vs new - phase based [N = 39]) and logistic regression used to assess the influence of patient factors and model of care on outcomes. RESULTS: Compliance was equivalent between models of care and completion rates (formal discharge by therapist) were low (30-38%). The probability of a patient receiving objective strength assessment was associated with model of care, sex, BMI and number of sessions attended. The probability of a patient being recorded as discharged from the program was significantly associated with model of care, and duration and number of sessions. CONCLUSION: Introduction of an updated model of care including a phase-based rehabilitation program increased physiotherapist utilisation of objective outcome measures in line with current ACLR rehabilitation recommendations, increased total rehabilitation duration and increased total number of sessions attended. Despite this, rehabilitation completion rates remained low, and self-reported activity and knee function remained equivalent. LEVEL OF EVIDENCE: III, retrospective cohort study.

Validity of intraoperative imageless navigation (Naviswiss) for component positioning accuracy in primary total hip arthroplasty: protocol for a prospective observational cohort study in a single-surgeon practice.

INTRODUCTION: Optimal outcomes in total hip arthroplasty (THA) are dependent on appropriate placement of femoral and acetabular components, with technological advances providing a platform for guiding component placement to reduce the risk of malpositioned components during surgery. This study will validate the intraoperative data captured using a handheld imageless THA navigation system against postoperative measurements of acetabular inclination, acetabular version, leg length and femoral offset on CT radiographs. METHODS AND ANALYSIS: This is a prospective observational cohort study conducted within a single-centre, single-surgeon private practice. Data will be collected for 35 consecutive patients (>18 years) undergoing elective THA surgery, from the research registry established at the surgeon's practice. The primary outcome is the agreement between intraoperative component positioning data captured by the navigation system compared with postoperative measurements using CT. A total of ten CT scans will be reassessed for interobserver and intraobserver reliability. The influence of patient and surgical factors on the accuracy of component position will also be examined with multivariable linear regression. ETHICS AND DISSEMINATION: Ethics approval for this study was provided through a certified ethics committee (Bellberry HREC approval number 2017-07-499). The results of this study will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) Trial ID: ACTRN12620000089932.

Multimodal thromboprophylaxis in low-risk patients undergoing lower limb arthroplasty: A retrospective observational cohort analysis of 1400 patients with ultrasound screening.

PURPOSE: This study reports the results of a multimodal thromboprophylaxis protocol for lower limb arthroplasty involving risk stratification, intraoperative calf compression, aspirin prophylaxis and early (within 4 h) post-operative mobilisation facilitated by the use of local infiltration analgesia. The study also aimed to identify risk factors for venous thromboembolism (VTE) within a 3-month period following surgery for patients deemed not at elevated risk. METHODS: Patients undergoing knee/hip arthroplasty or hip resurfacing were preoperatively screened for VTE risk factors, and those at standard risk were placed on a thromboprophylaxis protocol consisting of intraoperative intermittent calf compression during surgery, 300 mg/day aspirin for 6 weeks from surgery and early mobilisation. Patients were screened bilaterally for deep vein thrombosis (DVT) on post-operative days 10-14. If proximal DVT was detected, patients were anticoagulated and outcomes were recorded. Symptomatic VTE within 3 months of surgery were recorded separately. Patient notes were retrospectively collated and cross-validated against ultrasound reports. RESULTS: At initial screening, the rate of proximal DVT was 0.54% (1.1% for knee and 0.27% for hip), and distal DVT was 6.63% (20.11% for knee and 2.31% for hip). One small, nonfatal pulmonary embolism (PE) was detected within 3 months of surgery (0.28% of total knee arthroplasty patients or 0.07% of total). All proximal DVTs were treated successfully with anticoagulants; however, one patient suffered a minor PE approximately 10 months post-operatively. Regression analysis identified knee implant and advanced age as independent risk factors for VTE in this cohort. CONCLUSION: Although knee arthroplasty patients remained at higher risk than hip replacement/resurfacing patients, the incidence and outcomes of VTE remained positive compared with protocols involving extended immobilisation, and episodes of PE were extremely rare. Thus, we conclude that patients at standard preoperative risk of VTE may safely be taken through the post-operative recovery process with a combination of intraoperative mechanical prophylaxis, early mobilisation and post-operative aspirin, with closer attention required for older patients and those undergoing knee surgery.

Implementation and quality assessment of a clinical orthopaedic registry in a public hospital department.

BACKGROUND: The aim of this study was to demonstrate a novel method of assessing data quality for an orthopaedic registry and its effects on data quality metrics. METHODS: A quality controlled clinical patient registry was implemented, comprising six observational cohorts of shoulder and knee pathologies. Data collection procedures were co-developed with clinicians and administrative staff in accordance with the relevant dataset and organised into the registry database software. Quality metrics included completeness, consistency and validity. Data were extracted at scheduled intervals (3 months) and quality metrics reported to stakeholders of the registry. RESULTS: The first patient was enrolled in July 2017 and the data extracted for analysis over 4 quarters, with the last audit in August 2018 (N = 189). Auditing revealed registry completeness was 100% after registry deficiencies were addressed. However, cohort completeness was less accurate, ranging from 12 to 13% for height & weight to 90-100% for operative variables such as operating surgeon, consulting surgeon and hospital. Consistency and internal validation improved to 100% after issues in registry processes were rectified. CONCLUSIONS: A novel method to assess data quality in a clinical orthopaedic registry identified process shortfalls and improved data quality over time. Real-time communication, a comprehensive data framework and an integrated feedback loop were necessary to ensure adequate quality assurance. This model can be replicated in other registries and serve as a useful quality control tool to improve registry quality and ensure applicability of the data to aid clinical decisions, especially in newly implemented registries. TRIAL REGISTRATION: ACTRN12617001161314; registration date 8/08/2017. Retrospectively registered.

Limited penetration of cobalt and chromium ions into the cerebrospinal fluid following metal on metal arthroplasty: a cross-sectional analysis.

Background: The purpose of this study was to determine the concentration of cobalt (Co) and chromium (Cr) ions in synovial fluid, blood plasma and cerebrospinal fluid (CSF) of patients with metal-on-metal (MoM) implants, and to assess the relationship between implant history and patient characteristics with ion concentrations in CSF.Methods: An observational, non-randomised cross-sectional study was conducted with patients presenting to a single surgeon for treatment of degenerative conditions of the hip and knee. Blood and fluid samples were collected intraoperatively and analysed for proteins and trace elements.Results: Overall, the presence of an implant was associated with significantly higher Co and Cr concentrations in plasma (controls 5-115 nmol/L Co, 5-232 nmol/L Cr; well-functioning implant recipients 5-469 nmol/L Co, 5-608 nmol/L Cr; hip revisions 6-546 nmol/L Co, 5-573 nmol/L Cr), and for Cr concentrations in CSF (controls 5-24 nmol/L; well-functioning implant recipients 6-36 nmol/L, hip revisions 7-32 nmol/L). In absolute terms, <1% of the levels observed in the joint fluid and <15% of plasma metals appeared in the CSF. Multivariable regression models suggested different transfer mechanisms of Co and Cr to the CSF, with the presence of an implant not associated with ion levels.Conclusion: The presence of MoM implants is associated with significantly higher plasma levels of Co and Cr but not CSF levels, and the CSF/plasma ratio appears to be influenced by the plasma concentration in a nonlinear fashion. Co and Cr may be transferred to the CSF by different mechanisms, and their concentrations appears dependent on other factors yet to be identified. Although higher levels of plasma ions are associated with above average CSF metal concentrations, the thresholds for neurotoxicity remain unclear and require further study.

Efficacy of a Second-Generation Rotating Bearing Tibial Platform in Total Knee Arthroplasty: A Prospective Observational Cohort Study with Registry Analysis.

There is a lack of clinical outcomes reported for the rotating bearing knee (RBK) total knee arthroplasty (TKA), which is a second-generation rotating platform knee, with purported benefits over earlier versions. The purpose of the study was to report the complications, short-term (minimum 1 year) patient-reported outcomes and long-term (up to 15 years) procedure survival in a consecutive series of patients receiving a rotating platform TKA (RBK) from an independent clinic. A retrospective analysis of a single-surgeon, private/public practice, with prospectively collected data in a subset of patients were performed. A total of 1,130 procedures (primary, revision from unicompartmental knee arthroplasty (UKA) to TKA) were crossmatched with manufacturer records. Clinical outcomes (complications, reoperations) were summarized and linked to patient-reported outcome measures (Eq. 5D, KSS-function, Oxford knee score [OKS]). OKS results were classified using minimally clinical important difference (MCID) and patient acceptable symptom state (PASS). PROMs were summarized and regression models used to determine relationships between patient factors and outcomes in this cohort. Cumulative percent revision was reported by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and compared between the senior author and national data using Kaplan-Meier survival analysis. We report a complication rate of 19.7% with the majority (> 60%) being thromboembolic events and complaints of stiffness. Significant improvements were observed in general health, knee pain, and function with > 89% exceeding the MCID for the OKS and > 65% exceeding the PASS for the OKS at an average follow-up of 3.2 years. We report a cumulative revision rate of 4.3% at 5 years and 4.8% at 14 years, with significantly lower revision rates in females and patients aged 55 to 64 years compared with AOANJRR data for fixed bearing designs. The RBK rotating platform TKA provides good functional outcomes, with relatively low revision and complications rates at up to 14 years follow-up. This design in conjunction with a gap balancing technique may be advantageous in certain patient subgroups.