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BACKGROUND: Exercise is recommended as first-line treatment for patients with hip osteoarthritis (OA). However, randomized controlled trials providing evidence for the optimal exercise type are lacking. OBJECTIVE: To investigate whether progressive resistance training (PRT) is superior to neuromuscular exercise (NEMEX) for improving functional performance in patients with hip OA. DESIGN: Multicenter, cluster-randomized, controlled, parallel-group, assessor-blinded, superiority trial. (ClinicalTrials.gov: NCT04714047). SETTING: Hospitals and physiotherapy clinics. PARTICIPANTS: 160 participants with clinically diagnosed hip OA were enrolled from 18 January 2021 to 28 April 2023 and randomly assigned to PRT (n = 82) or NEMEX (n = 78). INTERVENTION: Twelve weeks of PRT or NEMEX with 2 supervised 60-minute group sessions each week. The PRT intervention consisted of 5 high-intensity resistance training exercises targeting muscles at the hip and knee joints. The NEMEX intervention included 10 exercises and emphasized sensorimotor control and functional stability. MEASUREMENTS: The primary outcome was change in the 30-second chair stand test (30s-CST). Key secondary outcomes were changes in scores on the pain and hip-related quality of life (QoL) subscales of the Hip Disability and Osteoarthritis Outcome Score (HOOS). RESULTS: The mean changes from baseline to 12-week follow-up in the 30s-CST were 1.5 (95% CI, 0.9 to 2.1) chair stands with PRT and 1.5 (CI, 0.9 to 2.1) chair stands with NEMEX (difference, 0.0 [CI, -0.8 to 0.8] chair stands). For the HOOS pain subscale, mean changes were 8.6 (CI, 5.3 to 11.8) points with PRT and 9.3 (CI, 5.9 to 12.6) points with NEMEX (difference, -0.7 [CI, -5.3 to 4.0] points). For the HOOS QoL subscale, mean changes were 8.0 (CI, 4.3 to 11.7) points with PRT and 5.7 (CI, 1.9 to 9.5) points with NEMEX (difference, 2.3 [CI, -3.0 to 7.6] points). LIMITATION: Participants and physiotherapists were not blinded. CONCLUSION: In patients with hip OA, PRT is not superior to NEMEX for improving functional performance, hip pain, or hip-related QoL. PRIMARY FUNDING SOURCE: Independent Research Fund Denmark.
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Osteoartrite do Quadril , Qualidade de Vida , Treinamento Resistido , Humanos , Osteoartrite do Quadril/reabilitação , Osteoartrite do Quadril/terapia , Osteoartrite do Quadril/fisiopatologia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Terapia por Exercício/métodos , Método Simples-CegoRESUMO
Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post-operative recovery between spinal anaesthesia and general anaesthesia; however, up-to-date comparisons in fast-track setups are needed. Our randomized, single-blinded, multi-centre, clinical trials aim to compare the post-operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast-track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0-2.0 mg/kg iv with Remifentanil 3-5 mcg/kg iv. Infusion: Propofol 3-5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast-track setup with intraoperative local infiltrative analgesia in TKA and UKA, post-operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in-hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5-m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post-operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30-days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast-track arthroplasty surgery.
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Raquianestesia , Artroplastia de Quadril , Artroplastia do Joelho , Propofol , Tromboembolia Venosa , Humanos , Raquianestesia/métodos , Artroplastia do Joelho/efeitos adversos , Remifentanil , Analgésicos Opioides , Anticoagulantes , Tromboembolia Venosa/etiologia , Anestesia Geral/métodos , Artroplastia de Quadril/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
PURPOSE: Some patients with anterior cruciate ligament (ACL) injury initially treated with rehabilitation need ACL reconstruction (ACLR); yet, it is unclear what characterizes these patients. This review aimed to describe predictors for ACLR in patients initially treated with rehabilitation. METHODS: A systematic literature search was performed in the Cochrane, Embase, Medline, SportsDiscus and Web of Science databases from inception to 21 February 2023. Articles describing characteristics in adult patients with ACL injury undergoing ACLR after a minimum of 5 weeks rehabilitation were included. It was a priori chosen that characteristics described in at least three articles were considered more certain and could be defined as a predictor for ACLR, and those described in less than three articles were considered less certain and therefore defined as possible predictors. Articles were screened by two independent reviewers. The study was originally intended as a systematic review with meta-analysis, but in case of limited data, we would convert it to a scoping review, as was the case for this review. RESULTS: There were 22,836 studies identified, and 181 full texts were screened, of which 10 papers were finally included. Only lower age and higher preinjury activity level were identified as predictors for ACLR. Another 12 possible predictors were identified in single studies. Through an iterative process, potential predictors were categorized into four groups: patient demographics, knee function, patient-reported outcome measures and anatomical structures. CONCLUSION: Lower age and higher preinjury activity level were the only predictors for ACLR after initial treatment with rehabilitation. While younger and highly active patients show a higher need for ACLR, more studies focussing on predictors and reasons for delayed ACLR are warranted. LEVEL OF EVIDENCE: Level II.
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BACKGROUND: Prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a complication associated with increased risk of death. There is limited knowledge about the association between infection before THA, and risk of revision due to PJI. We investigated the association between any previous hospital-diagnosed or community-treated infection 0 to 6 months before primary THA and the risk of revision. METHODS: We obtained data on 58,449 patients who were operated with primary unilateral THA between 2010 and 2018 from the Danish Hip Arthroplasty Register. Information on previous infection diagnoses, redeemed antibiotic prescriptions up to 1 year before primary THA, intraoperative biopsies, and cohabitations was retrieved from Danish health registers. All patients had a 1-year follow-up. Primary outcome was revision due to PJI. Secondary outcome was any revision. We calculated the adjusted relative risk with 95% confidence intervals (CI), treating death as competing risk. RESULTS: Among 1,507 revisions identified, 536 were due to PJI with a cumulative incidence of 1.0% ([CI] 0.9 to 1.2) and 0.9% ([CI] 0.8 to 1.0) for patients who did and did not have previous infection. For any revision, the cumulative incidence was 3.1% ([CI] 2.9 to 3.4) and 2.4% ([CI] 2.3 to 2.6) for patients who did and did not have previous infection. The adjusted relative risk for PJI revision was 1.1 ([CI] 0.9 to 1.4) and for any revision 1.3 ([CI] 1.1 to 1.4) for patients who did have previous infection compared to those who did not. CONCLUSION: Previous hospital-diagnosed or community-treated infection 0 to 6 months before primary THA does not increase the risk of PJI revision. It may be associated with increased risk of any revision.
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Artroplastia de Quadril , Prótese de Quadril , Osteoartrite , Infecções Relacionadas à Prótese , Humanos , Artroplastia de Quadril/efeitos adversos , Estudos de Coortes , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/cirurgia , Risco , Osteoartrite/cirurgia , Reoperação/efeitos adversos , Fatores de Risco , Prótese de Quadril/efeitos adversos , Estudos Retrospectivos , Sistema de RegistrosRESUMO
BACKGROUND: Noises have been associated with ceramic-on-ceramic bearings in total hip arthroplasties. The etiology is multifactorial, but a high prevalence of noises was reported in studies using a specific acetabular component system. We examined if specific ceramic component designs are associated with the prevalence of noises in 2 commonly used component systems. We hypothesized that there would be no difference in noises between the 2 systems. METHODS: In this randomized controlled trial, 2 different component designs with ceramic bearings were compared. Inclusion criteria were primary total hip arthroplasties, age between 18 and 65 years, and body mass index less than 35. The primary outcome was prevalence of noises, whereas secondary outcomes consisted of European Quality of Life index, visual analog scale, and University of California and Los Angeles activity scale. Follow-up data were collected at 3 and 12 months postoperatively. Data were available for 91 patients in Group 1 and for 92 patients in Group 2. Preoperative patient characteristics were comparable between groups. RESULTS: At 12-month follow-up, the prevalence of noises was 19% in Group 1 and 14% in Group 2 (P = .41). European Quality of Life index were 0.89 in Group 1 versus 0.90 in Group 2 (P = .42). The visual analog scale was 81 in both groups (P = .88). When evaluating level of activity, University of California and Los Angeles activity scale scores were 8.2 in both groups (P = .92). CONCLUSION: At 12-month follow-up, there was no difference in the prevalence of noises between the 2 component designs.
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Artroplastia de Quadril , Prótese de Quadril , Humanos , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Estudos Prospectivos , Qualidade de Vida , Cerâmica , Desenho de Prótese , Seguimentos , Resultado do Tratamento , Falha de PróteseRESUMO
BACKGROUND: The effect of metabolic syndrome (MetS) on the risk of revision after hip and knee arthroplasty is debated. The aim of our study was to investigate the risk of short-term (minimum 2.7 years) revision due to periprosthetic joint infection (PJI) after hip and knee arthroplasty. Secondly, we aimed to investigate the risk of revision due to any cause and mortality. METHODS: During May 2017 to November 2019, a cohort of 2,901 patients undergoing a total of 3,024 hip and knee arthroplasties was established. In the cohort, 62.1% met the criteria for MetS. Data from national registries and a local database were used to determine the presence of MetS and revision surgeries, with a follow-up of at least two years and eight months. Cox regression was applied to the present hazard ratio (HR), associated 95% confidence intervals, and P values. Survival analyses were presented in a Kaplan-Meier plot. RESULTS: The risk of PJI (HR 1.6 (0.5 to 4.9), P = .380), any revision (HR 0.8 (0.4 to 1.3), P = .295), and death (HR 1.3 (0.8 to 2.1), P = .282) was not increased in patients suffering from MetS compared with patients who did not have MetS. There was no PJI in patients not having MetS and receiving a knee arthroplasty. The risk of death was increased in the MetS group receiving a knee arthroplasty (HR 2.7 (1.3 to 5.9), P = .010), but not different from the MetS group receiving a hip arthroplasty. There was no elevated risk of PJI when analyzing morbid obesity (body mass index over 40), men, or diabetes as the exposures. CONCLUSIONS: Patients suffering from MetS do not have an increased risk of revision caused by PJI. In general, performing hip and knee arthroplasty in patients suffering from MetS is without increased risk of revision surgery.
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Heart rate variability (HRV) is a measure of the autonomic nervous system function and possibly related to postoperative outcome. Despite several HRV studies in different surgical settings, optimal indices and timepoints for measuring have not been adequately determined. Consequently, there is a need for detailed descriptive procedure-specific studies on the time-course of perioperative HRV within a modern fast-track surgical setting. We measured HRV continuously in 24 patients from 4 days before until 9 days after total hip arthroplasty (THA). Statistical methods included mainly ANOVA and t-tests or Kruskal-Wallis and pairwise Wilcoxon test. Patients completed the Orthostatic Discriminant and Severity Scale five times during the study describing autonomic nervous system dysfunction. Standard deviation between normal-to-normal beats and the total power of HRV were reduced for at least 9 days following THA, with a trend towards increased HRV leading up to the day of surgery. The balance between low- and high-frequency power of HRV was reduced in the postoperative evenings. There was increased orthostatic intolerance symptoms on the first postoperative day, with symptoms of pain, fatigue and weakness decreasing after the first postoperative day. Median hospital stay was 1 day. We provide the first detailed description of perioperative time-course of HRV and orthostatic symptoms in fast-track THA, showing reduced HRV after surgery for at least a week, and that HRV changes are sensitive to time of day and timing before and after surgery. These results are helpful in designing future HRV studies in perioperative risk assessment and outcome.
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Artroplastia de Quadril , Humanos , Frequência Cardíaca/fisiologiaRESUMO
BACKGROUND AND PURPOSE: Length of hospital stay after hip and knee arthroplasty is about 1 day in Denmark with few patients discharged on the day of surgery. Hence, a protocol for multicenter implementation of discharge on day of surgery has been instituted. We aimed to describe the implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting. METHODS: We performed a prospective multicenter study from 7 public hospitals across Denmark. Patients were screened using well-defined in- and exclusion criteria and were discharged on day of surgery when fulfilling functional discharge criteria. The study period was from September 2022 to February 2023 with variable start of implementation. Data from the same centers in a 6-month period before the COVID pandemic from July 2019 to December 2019 was used for baseline control. RESULTS: Of 2,756 primary hip and knee arthroplasties, 37% (95% confidence interval [CI] 35-39) were eligible (range 21-50% in centers) and 52% (range 24-62%) of these were discharged on day of surgery. 21% (CI 20-23) of all patients (eligible and non-eligible) were discharged on day of surgery with a range of 10-31% within centers. This was an additional 15% (CI 13-17, P < 0.001) compared with patients discharged in the control period (6% in 2019). CONCLUSION: We found it possible to perform outpatient hip and knee replacement in 21% of patients in a public healthcare setting, probably to be increased with further center experience.
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Artroplastia de Quadril , Artroplastia do Joelho , Humanos , Artroplastia do Joelho/métodos , Artroplastia de Quadril/métodos , Estudos Prospectivos , Dinamarca , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , COVID-19/prevenção & controle , COVID-19/epidemiologia , Procedimentos Cirúrgicos Ambulatórios , Tempo de Internação , Alta do Paciente , Hospitais Públicos/estatística & dados numéricos , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking. METHODS: A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg-1vs 0.3 mg kg-1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90. RESULTS: A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8-1.4, P=0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6-25] mg L-1vs 16 [9-38] mg L-1, P = 0.07), but lower at 48 h (26 [9-52] mg L-1vs 50 [30-72] mg L-1, P<0.01) in the high-dose group. CONCLUSION: Use of 1 mg kg-1vs 0.3 mg kg-1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population. CLINICAL TRIAL REGISTRATION: NCT03758170 (first registration 29-11-2018).
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Antieméticos , Artroplastia do Joelho , Humanos , Artroplastia do Joelho/efeitos adversos , Antieméticos/uso terapêutico , Proteína C-Reativa , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/diagnóstico , Analgésicos Opioides , Dexametasona/uso terapêutico , Método Duplo-Cego , Anestésicos LocaisRESUMO
BACKGROUND: Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain. METHODS: An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions. RESULTS: A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell. CONCLUSION: Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.
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Artroplastia de Quadril , Artroplastia do Joelho , Humanos , Tempo de Internação , Readmissão do Paciente , Artroplastia do Joelho/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Analgésicos Opioides , Artroplastia de Quadril/efeitos adversosRESUMO
Pain after total knee arthroplasty (TKA) is a well-known clinical problem potentially delaying ambulation and recovery. Perioperative glucocorticoids reduce pain and facilitate early recovery, but the optimal timing and dose are still unknown. High pain catastrophizers have an increased risk of poorly controlled postoperative pain, and moderate to severe pain at 24 h is associated with a risk of pain relapse at 48 h. To evaluate the effect of a repeat moderate dose of glucocorticoids after TKA in high pain catastrophizers presenting with moderate to severe pain 24 h postoperatively, having received preoperative high-dose glucocorticoids. High pain catastrophizers (Pain Catastrophizing Scale > 20) undergoing TKA are screened 24 h postoperatively and are included if they experience moderate to severe pain (VAS > 30) during a 5 m walk test. The included patients will receive either oral 24 mg dexamethasone (n = 55) or placebo (n = 55) on the evening of Day 1 (~30-37 h) after surgery. In addition, patients receive a standard multimodal analgesic regimen, including paracetamol, celecoxib, local infiltration analgesia, and preoperative dexamethasone (1 mg/kg). Patients will fill out a pain diary for 7 days after surgery. The primary outcome is moderate to severe pain (VAS > 30) during a 5 m walk test on the morning of Day 2 after surgery. The secondary outcomes include cumulated pain at rest and during ambulation, cumulated use of rescue analgesics, quality of sleep, lethargy, dizziness, nausea, satisfaction with the analgesic regimen, length of stay, morbidity, mortality, and reasons for readmissions. Follow-up is at 8 and 30 days. The data from this study will provide evidence for the effect of a repeated dose of dexamethasone as an analgesic adjuvant in patients undergoing TKA with a high risk of postoperative pain.
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Artroplastia do Joelho , Humanos , Analgésicos/uso terapêutico , Analgésicos Opioides , Artroplastia do Joelho/efeitos adversos , Dexametasona/uso terapêutico , Método Duplo-Cego , Glucocorticoides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologiaRESUMO
BACKGROUND: The RECIPE trial systematically investigates the effects of different combinations of paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty. To preserve transparency, minimise risk of bias and to prevent data-driven analysis, we present this detailed statistical analysis plan. METHODS: The RECIPE trial is a randomised, blinded, parallel four-group multicenter clinical trial for patients undergoing planned primary total hip arthroplasty. Interventions are initiated preoperatively and continued for 24 h postoperatively. Primary outcome is total opioid consumption 0-24 h after end of surgery. Primary analysis will be performed in the modified intention to treat population of all patients undergoing total hip arthroplasty, and all analyses will be stratified for site. We will perform pairwise comparisons between each of the four groups. The primary outcome will be analysed using the van Elteren test and we will present Hodges-Lehmann median differences and confidence intervals. Binary outcomes will be analysed using logistic regression. To preserve a family-wise error rate of <0.05, we will use a Bonferroni-adjusted alfa of 0.05/6 = 0.0083 for all six pairwise comparisons between groups when analysing the primary outcome. We will systematically assess the underlying statistical assumptions for each analysis. Data will be analysed by two blinded independent statisticians, and we will write abstracts covering all possible combinations of conclusions, before breaking the blind. DISCUSSION: The RECIPE trial will provide important information on benefit and harm of combinations of the most frequently used non-opioid analgesics for pain after primary hip arthroplasty.
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Analgésicos não Narcóticos , Artroplastia de Quadril , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Acetaminofen/uso terapêutico , Analgésicos não Narcóticos/uso terapêutico , Ibuprofeno/uso terapêutico , Analgésicos Opioides/uso terapêuticoRESUMO
BACKGROUND: Machine-learning models may improve prediction of length of stay (LOS) and morbidity after surgery. However, few studies include fast-track programs, and most rely on administrative coding with limited follow-up and information on perioperative care. This study investigates potential benefits of a machine-learning model for prediction of postoperative morbidity in fast-track total hip (THA) and knee arthroplasty (TKA). METHODS: Cohort study in consecutive unselected primary THA/TKA between 2014-2017 from seven Danish centers with established fast-track protocols. Preoperative comorbidity and prescribed medication were recorded prospectively and information on length of stay and readmissions was obtained through the Danish National Patient Registry and medical records. We used a machine-learning model (Boosted Decision Trees) based on boosted decision trees with 33 preoperative variables for predicting "medical" morbidity leading to LOS > 4 days or 90-days readmissions and compared to a logistical regression model based on the same variables. We also evaluated two parsimonious models, using the ten most important variables in the full machine-learning and logistic regression models. Data collected between 2014-2016 (n:18,013) was used for model training and data from 2017 (n:3913) was used for testing. Model performances were analyzed using precision, area under receiver operating (AUROC) and precision recall curves (AUPRC), as well as the Mathews Correlation Coefficient. Variable importance was analyzed using Shapley Additive Explanations values. RESULTS: Using a threshold of 20% "risk-patients" (n:782), precision, AUROC and AUPRC were 13.6%, 76.3% and 15.5% vs. 12.4%, 74.7% and 15.6% for the machine-learning and logistic regression model, respectively. The parsimonious machine-learning model performed better than the full logistic regression model. Of the top ten variables, eight were shared between the machine-learning and logistic regression models, but with a considerable age-related variation in importance of specific types of medication. CONCLUSION: A machine-learning model using preoperative characteristics and prescriptions slightly improved identification of patients in high-risk of "medical" complications after fast-track THA and TKA compared to a logistic regression model. Such algorithms could help find a manageable population of patients who may benefit most from intensified perioperative care.
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Artroplastia de Quadril , Artroplastia do Joelho , Humanos , Estudos de Coortes , Artroplastia do Joelho/efeitos adversos , Modelos Logísticos , Morbidade , Aprendizado de Máquina , Artroplastia de Quadril/efeitos adversos , Tempo de InternaçãoRESUMO
OBJECTIVE: To compare the effect of early surgery versus exercise and education on mechanical symptoms and other patient-reported outcomes in patients aged 18-40 years with a meniscal tear and self-reported mechanical knee symptoms. METHODS: In a randomised controlled trial, 121 patients aged 18-40 years with a MRI-verified meniscal tear were randomised to surgery or 12-week supervised exercise and education. For this study, 63 patients (33 and 30 patients in the surgery and in the exercise group, respectively) reporting baseline mechanical symptoms were included. The main outcome was self-reported mechanical symptoms (yes/no) at 3, 6 and 12 months assessed using a single item from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes were KOOS4 and the 5 KOOS-subscales and the Western Ontario Meniscal Evaluation Tool (WOMET). RESULTS: In total, 55/63 patients completed the 12-month follow-up. At 12 months, 9/26 (35%) in the surgery group and 20/29 (69%) in the exercise group reported mechanical symptoms. The risk difference and relative risk at any time point was 28.7% (95% CI 8.6% to 48.8%) and 1.83 (95% CI 0.98 to 2.70) of reporting mechanical symptoms in the exercise group compared with the surgery group. We did not detect any between-group differences in the secondary outcomes. CONCLUSION: The results from this secondary analysis suggest that early surgery is more effective than exercise and education for relieving self-reported mechanical knee symptoms, but not for improving pain, function and quality of life in young patients with a meniscal tear and mechanical symptoms. TRIAL REGISTRATION NUMBER: NCT02995551.
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Traumatismos do Joelho , Osteoartrite do Joelho , Lesões do Menisco Tibial , Humanos , Qualidade de Vida , Artroscopia/métodos , Lesões do Menisco Tibial/cirurgia , Terapia por Exercício/métodos , Traumatismos do Joelho/cirurgia , Osteoartrite do Joelho/cirurgiaRESUMO
OBJECTIVE: To investigate potential differences in structural knee joint damage assessed by MRI and patient-reported outcomes (PROMs) at 2-year follow-up between young adults randomised to early surgery or exercise and education with optional delayed surgery for a meniscal tear. METHODS: A secondary analysis of a multicentre randomised controlled trial including 121 patients (18-40 years) with an MRI-verified meniscal tear. For this study, only patients with 2-year follow-up were included. The main outcomes were the difference in worsening of structural knee damage, assessed by MRI using the Anterior Cruciate Ligament OsteoArthrits Score, and the difference in change in the mean score of four Knee Injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sport and recreation, and quality of life, from baseline to 2 years. RESULTS: In total, 82/121 (68%) patients completed the 2-year follow-up (39 from the surgical group and 43 from the exercise group). MRI-defined cartilage damage had developed or progressed in seven (9.1%) patients and osteophytes developed in two (2.6%) patients. The worsening of structural damage from baseline to 2-year follow-up was similar between groups. The mean (95% CI) adjusted differences in change in KOOS4 between intervention groups from baseline to 2 years was -1.4 (-9.1, 6.2) points. The mean improvement in KOOS4 was 16.4 (10.4, 22.4) in the surgical group and 21.5 (15.0, 28.0) in the exercise group. No between group differences in improvement were found in the KOOS subscales. CONCLUSIONS: The 2-year worsening of MRI-defined structural damage was limited and similar in young adult patients with a meniscal tear treated with surgery or exercise with optional delayed surgery. Both groups had similar clinically relevant improvements in KOOS4, suggesting the choice of treatment strategy does not impact 2-year structural knee damage or PROMs. TRIAL REGISTRATION NUMBER: NCT02995551.
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Lesões do Ligamento Cruzado Anterior , Traumatismos do Joelho , Humanos , Adulto Jovem , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/complicações , Traumatismos do Joelho/complicações , Articulação do Joelho/cirurgia , Imageamento por Ressonância Magnética , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Adolescente , AdultoRESUMO
BACKGROUND: Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown. OBJECTIVE: To evaluate the effect of a high dose (1âmgâkg -1 ) vs. intermediate dose (0.3âmgâkg -1 ) of dexamethasone on pain after THA. DESIGN: A randomized double-blind controlled study. SETTING: A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020. PATIENTS: A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20âand/or preoperative opioid use were included. INTERVENTION: Patients were randomly assigned to receive dexamethasone 1âmgâkg -1 or 0.3âmgâkg -1 before THA. MAIN OUTCOME MEASURES: Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30âmm on a 0 to 100âmm scale) on ambulating 24âh after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days. RESULTS: No difference was found in percentage of VAS >30âmm 24âh after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative riskâ=â1.04 (95% confidence interval 0.72-1.51; P â=â0.814) in 1âmgâkg -1vs. 0.3âmgâkg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications. CONCLUSION: 1âmgâkg -1vs. 0.3âmgâkg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders. TRIAL REGISTRATION: ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.
Assuntos
Artroplastia de Quadril , Humanos , Artroplastia de Quadril/efeitos adversos , Analgésicos Opioides , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dexametasona , Método Duplo-CegoRESUMO
BACKGROUND AND PURPOSE: Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers. PATIENTS AND METHODS: This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Humanos , Alta do Paciente , Estudos Prospectivos , Tempo de Internação , Artroplastia do Joelho/métodos , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Estudos Multicêntricos como AssuntoRESUMO
BACKGROUND AND PURPOSE: The bearings with the best survivorship for young patients with total hip arthroplasty (THA) should be identified. We compared hazard ratios (HR) of revision of primary stemmed cementless THAs with metal-on-metal (MoM), ceramic-on-ceramic (CoC), and ceramic-on-highly-crosslinked-polyethylene (CoXLP) with that of metal-on-highly-crosslinked-polyethylene (MoXLP) bearings in patients aged 20-55 years with primary osteoarthritis or childhood hip disorders. PATIENTS AND METHODS: From the Nordic Arthroplasty Register Association dataset we included 1,813 MoM, 3,615 CoC, 5,947 CoXLP, and 10,219 MoXLP THA in patients operated on between 2005 and 2017 in a prospective cohort study. We used the Kaplan-Meier estimator for THA survivorship and Cox regression to estimate HR of revision adjusted for confounders (including 95% confidence intervals [CI]). MoXLP was used as reference. HRs were calculated during 3 intervals (0-2, 2-7, and 7-13 years) to meet the assumption of proportional hazards. RESULTS: Median follow-up was 5 years for MoXLP, 10 years for MoM, 6 years for CoC, and 4 years for CoXLP. 13-year Kaplan-Meier survival estimates were 95% (CI 94-95) for MoXLP, 82% (CI 80-84) for MoM, 93% (CI 92-95) for CoC, and 93% (CI 92-94) for CoXLP bearings. MoM had higher 2-7 and 7-13 years' adjusted HRs of revision (3.6, CI 2.3-5.7 and 4.1, CI 1.7-10). MoXLP, CoC, and CoXLP had similar HRs in all 3 periods. The 7-13-year adjusted HRs of revision of CoC and CoXLP were statistically non-significantly higher. CONCLUSION: In young patients, MoXLP for primary cementless THA had higher revision-free survival and lower HR for revision than MoM bearings. Longer follow-up is needed to compare MoXLP, CoC, and CoXLP.
Assuntos
Artroplastia de Quadril , Prótese de Quadril , Humanos , Criança , Artroplastia de Quadril/efeitos adversos , Prótese de Quadril/efeitos adversos , Estudos Prospectivos , Fatores de Risco , Polietileno , Metais , Cerâmica , Reoperação , Desenho de Prótese , Falha de PróteseRESUMO
BACKGROUND: Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking. METHODS: A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg-1 or intermediate-dose dexamethasone 0.3 mg kg-1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications. RESULTS: Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01). CONCLUSIONS: When compared with preoperative dexamethasone 0.3 mg kg-1 i.v., dexamethasone 1 mg kg-1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects. CLINICAL TRIAL REGISTRATION: NCT03763734.
Assuntos
Artroplastia do Joelho/métodos , Dexametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Proteína C-Reativa/metabolismo , Dexametasona/efeitos adversos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Glucocorticoides/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Cuidados Pré-Operatórios/métodos , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To assess the variation in changes in patient-reported outcomes 4 to 6 years after arthroscopic partial meniscectomy (APM). DESIGN: Prospective cohort study. SETTING: Orthopedic departments at public hospitals. PATIENTS: Patients (n = 447) from the Knee Arthroscopy Cohort Southern Denmark undergoing APM. INTERVENTIONS: All patients underwent APM. MAIN OUTCOME MEASURES: Change in KOOS4 scores from baseline before surgery to â¼5 years (range 4-6 years) after surgery. KOOS4 is the average aggregated score of 4 of 5 of the Knee injury and Osteoarthritis Outcome Score (KOOS) excluding the activities of daily living subscale (minimal clinical important improvement â¼10 points). A mixed linear model adjusted for sex and body mass index was used to assess change from baseline to â¼5-year follow-up. Change in KOOS4 was divided into 5 categories based on change from baseline to â¼5-year follow-up: <0 points, 0 to 9 points, 10 to 19 points, 20 to 29 points, and ≥30 points. RESULTS: On average, patient-reported outcomes continued to improve from baseline to â¼5-year follow-up (mean KOOS4 change: 26, 95% CI, 24-28). Proportions in the different response groups were <0 points (12%), 0 to 9 points (13%), 10 to 19 points (16%), 20 to 29 points (19%), and ≥30 points (40%), with no difference between younger (≤40 years, n = 75) and older (>40 years, n = 337) patients (P = 0.898). CONCLUSIONS: Patient-reported outcomes on average improved up to â¼5 years after APM; however, large variability was observed. The similar variability in younger and older patients questions the assumption that younger patients with traumatic injuries experience larger benefits from APM.