Ten-year follow-up of a total knee prosthesis combining multi-radius, ultra-congruency, posterior-stabilization and mobile-bearing insert shows long-lasting clinically relevant improvements in pain, stiffness, function and stability.

PURPOSE: There is a paucity of data available on total knee prostheses combining dual-radius, ultra-congruency, posterior-stabilization and mobile-bearing insert. This prospective cohort study aimed to assess the clinical evolution of the FIRST® prosthesis (Symbios Orthopédie, Yverdon, CH), the earliest prosthesis with this particular design. It was hypothesized that the primary outcomes, evaluating pain, stiffness, function and stability, would improve following arthroplasty and remain improved during the follow-up period of 10 years. METHODS: All patients programmed for a total knee arthroplasty using a FIRST® prosthesis at our university hospital between 2006 and 2008 were invited to participate. Study knees were evaluated pre-operatively as well as one, five and ten years post-operatively. Patients filled out questionnaires at each evaluation point and had a radiographic assessment at the five-year and ten-year follow-ups. Primary outcomes were the total, pain, stiffness and function measures of the Western Ontario and McMaster Universities Osteoarthritis questionnaire (WOMAC) and the knee and function measures of the Knee Society Score (KSS). Friedman and Wilcoxon's rank-sum tests were used to compare measures across time points. RESULTS: Hundred and twenty four prostheses were included (baseline demographics: 69.9 ± 8.3 years old, 28.1 ± 4.3 kg/m2, 54% male) and 68 could be followed during ten years. Five prostheses underwent a revision. All other prostheses lost at follow-up were lost for reasons unrelated to the prosthesis. All primary measures reported statistically and clinically significant improvements between baseline and the three follow-up evaluations. Statistically significant improvements at the three follow-up evaluations were also observed for most secondary measures. There was no implant loosening. At ten-year follow-up, radiolucent lines were observed in 2.9% femoral implants and 1.5% tibial implants. CONCLUSION: The positive results observed in all domains of assessment and the small revision rate demonstrated an effective functioning of the FIRST® prosthesis during the ten-year follow-up period. The results, globally similar to those previously published for other prosthesis designs, encourage the development of assistive methods to select the most appropriate designs on an individual basis. LEVEL OF EVIDENCE: IV, prospective cohort study.

Are the Cumulated Ambulation Score and Risk Assessment and Prediction Tool useful for predicting discharge destination and length of stay following total knee arthroplasty?

BACKGROUND: Postoperative management of patients undergoing total knee arthroplasty (TKA) is continually changing. Costs related to TKA are driven by implant cost, operating room cost, hospital length of stay (LOS), and rehabilitation approach. Discharges to rehabilitation centers have declined significantly in recent years. AIM: We evaluated the usefulness of the Cumulated Ambulation Score (CAS) and Risk Assessment and Prediction Tool (RAPT) to predict discharge destination and estimate hospital LOS of patients undergoing TKA. DESIGN: Prospective cohort study. SETTING: University hospital inpatients. POPULATION: Patients undergoing elective primary TKA. METHODS: Consecutive patients were prospectively evaluated. Outcome measures were discharge destination and LOS dichotomized at the median (LOS<8 versus LOS≥8). Patients completed five outcome questionnaires and knee range of motion was measured preoperatively. RAPT was considered continuous, and also dichotomized (RAPT≤9 versus RAPT>9; RAPT9). CAS was dichotomized (CAS<11 versus CAS≥11; CAS11). Surgical technique and aftercare were similar for all patients. RESULTS: Sixty-four patients (37 females), mean age 69.3±10.2 years were evaluated. CAS11 and discharge destination were strongly associated: 75.9% of patients with CAS≥11 were discharged home; 85.7% of patients with CAS<11 were discharged to a rehabilitation center (P<0.001). 80.7% of patients with RAPT≤9 were discharged to a rehabilitation center, versus 36.4% of patients with RAPT>9 (P=0.002). Odds ratios for discharge home were 18.9 (CAS11) and 7.3 (RAPT). CAS11 and RAPT were not related to LOS. CONCLUSIONS: The CAS and RAPT can assist clinicians in estimating the discharge destination and developing patient care plans following TKA. However, predicting LOS with such tools alone was inaccurate. CLINICAL REHABILITATION IMPACT: Use of the CAS and RAPT can inform discharge destination and patient care plans following TKA and has the potential to optimise resources and costs. However, due to social and organizational constraints on discharge, predicting LOS with such tools alone revealed to be inaccurate.

Efficiency of the lausanne clinical pathway for proximal femoral fractures.

UNLABELLED: Purpose/Introduction: The number of hip fractures is rising, due to increases in life expectancy. In such cases, patients are at risk from post-operative complications and subsequently the average length of hospitalization may be extended. In 2011, we established a clinical pathway (CP), a specific model of care for patient-care management, to improve the clinical and economic outcomes of proximal femoral fracture management in elderly patients. The goal was to evaluate the CP using clinical, process, and financial indicators. METHODS: We included all surgical patients aged 65 and over, admitted to the emergency department with a fracture of the proximal femur following a fall. Assessment parameters included three performance indicators: clinical, process, and financial. The clinical indicators were the presence or absence of acute delirium on the third post-operative day, diagnosis of nosocomial pneumonia, and the number of patients fulfilling at least 75% of their nutritional requirements at the end of the hospitalization period. The process indicator was the time interval between arrival at the emergency department and surgery. The financial indicator was based on the number of days spent in hospital. RESULTS: From 2011 to 2013, 669 patients were included in the CP. We observed that the average length of stay in hospital decreased as soon as the CP was implemented and stabilized afterwards. The goal of 90% of patients undergoing surgery within 48 h of arrival in the emergency department was surpassed in 2013 (93.1%). Furthermore, we observed an improvement in the clinical indicators. CONCLUSION: The application of a CP allowed an improvement in the qualitative and quantitative efficiency of proximal femoral fracture management in elderly patients, in terms of clinical, process, and financial factors.