How Much Does Prosthetic Joint Infection and Its Successful Treatment Affect Patient-reported Quality of Life?

BACKGROUND: Uncomplicated joint replacement improves pain and other patient-reported outcome measures (PROMs) such as joint function scores and quality-of-life measures. However, the overall impact of periprosthetic joint infection (PJI) and its successful treatment on PROMs is poorly defined. In this study, we describe quality-of-life scores using the 12-item Short Form survey, version 2 (SF-12v2), collected as part of a large, prospective, observational study of PJI. QUESTIONS/PURPOSES: (1) Do patients with newly diagnosed PJI have lower quality-of-life scores than the general age-matched population? (2) Are lower quality-of-life scores for patients with PJI sustained for ≥ 12 months? (3) What factors are associated with a good functional outcome at 12 months, defined by achieving a physical component summary (PCS) score of > 50 on the SF-12v2 (that is, above the age-adjusted population mean) or an increase of > 8.9 or more from baseline? METHODS: The PIANO (Prosthetic joint Infection in Australia and New Zealand, Observational study) cohort was a prospective, longitudinal, multicenter cohort study of 783 patients with newly diagnosed PJI recruited across 27 centers between July 2014 and December 2017. All participants were followed for 2 years. SF-12v2 scores were collected at diagnosis (baseline) and 3, 12, and 24 months after diagnosis. Treatment success was defined as being alive with no clinical or microbiological evidence of infection and no ongoing use of antibiotics for the index joint. RESULTS: After exclusion of 6.6% (52) who had died, 4.2% (33) with PJI of joints other than hips and knees, and those with incomplete data sets (200 [25.5%]), 498 patients had complete SF-12v2 data sets available. At baseline, the median (IQR) PCS score was 37 (30 to 46), which increased to 41 (34 to 49; p < 0.001) at 12 months. Both measures were lower than those for the general age-matched population norm. There was no further improvement in PCS scores between 12 and 24 months. By contrast, the median (IQR) mental component summary score of the SF-12v2 was similar to age-adjusted population norms (48 [37 to 57]) at baseline. Only 40% of patients with PJI achieved a good functional outcome at 12 months. After adjustment for other factors, treatment success of PJI increased the odds of a good functional outcome by 67% (95% CI 11% to 154%; p = 0.02). CONCLUSION: PJIs have a large effect on the PCS score of the SF-12v2 quality-of-life measure at baseline, which is sustained for at least 2 years. Successful treatment of PJI increases the likelihood of a good functional outcome. These data can be used to set expectations for patients presenting with PJI and can be used to inform future clinical studies in which quality-of-life measures are incorporated into clinical endpoints. LEVEL OF EVIDENCE: Level II, therapeutic study.

Endoscopic Tendon Release for Iliopsoas Impingement After Total Hip Arthroplasty-Excellent Clinical Outcomes and Low Failure Rates at Short-Term Follow-Up.

PURPOSE: To investigate the clinical effectiveness of endoscopic iliopsoas tendon release (IPR) at the lesser trochanter (LT) in patients with iliopsoas impingement (IPI) after total hip arthroplasty (THA). METHODS: Between November 2017 and March 2021, a consecutive series of 36 patients were treated with endoscopic IPR for diagnosed IPI. Patients included had acetabular cup position confirmed by functional imaging (OPS, Corin, Pymble, NSW), typical clinical symptoms of IPI, and a positive response to diagnostic injection. Clinical assessment included validated patient-reported outcome measures (PROMs) along with hip flexion strength and active range of motion at different time marks up to 2-year follow-up, as well as surgical complications. RESULTS: Overall, 36 consecutive patients (11 males) with a mean age of 62 ± 12 years were included. All patients had failed nonoperative management. Dynamic computed tomography assessment was available in 89% of the patients, edge loading was reported in 10%, and variable cup overhang was reported in 50%. Clinically, PROMs were significantly improved at every time mark when compared with preoperative values (P < .001), showing the biggest improvement within the first 4 weeks after surgery. At the 6-month follow-up, peak isometric hip flexion strength on the operated side was 20% lower than the contralateral side (P < .001). Failure rate of the procedure was 2.8% (1 case). Linear regression showed no association between cup overhang and clinical outcomes. CONCLUSIONS: Endoscopic IPR at the LT is a safe and reproducible technique associated with significant and immediate improvement in pain, functional outcomes, and high patient satisfaction. With minimal short-term weakness, no complications, and only a single revision, even in cases with cup malposition and/or edge loading, we believe that endoscopic IPR can be considered as one of the first-line operative options in patients with symptomatic IPI, irrespective of component position. LEVEL OF EVIDENCE: Level IV, case series.

Medialized Dome and Anatomic Onlay Patella Designs in the Modern Posterior Stabilized Rotating Platform Total Knee Arthroplasty Demonstrate No Clinical or Radiological Differences at One Year.

BACKGROUND: A successful outcome after total knee arthroplasty (TKA) includes the restoration of patellofemoral function. Modern patella component designs in TKA include a medialized dome and more recently, an anatomic design. There is a paucity of literature comparing these 2 implants. METHODS: This prospective nonrandomized study examined 544 consecutive TKAs with patella resurfacing using a posterior-stabilized, rotating platform knee prothesis performed by a single surgeon. A medialized dome patella design was used in the first 323 cases and an anatomic design in the subsequent 221 cases. Patients were assessed preoperatively, at 4 weeks and 1-year post-TKA for Oxford Knee Score (OKS) (total, pain, and kneeling components) and range of movement (ROM). Radiolucent lines (RLLs), patellar tilts and displacements, as well as reoperations were assessed at 1-year post-TKA. RESULTS: At 1-year post-TKA, both groups demonstrated similar improvements in ROM, OKS, pain, and kneeling scores, and had a similar incidence of fixed-flexion deformity (all P > .05). Radiographically, there was no clinically significant difference in the incidence of RLLs, patellar tilts, and displacements. The prevalence of reoperations (1.8 versus 3.2%, P = .526) was similar between the designs with no patella-related complications. CONCLUSION: Both medialized dome and anatomic patella designs result in improved ROM and OKS with no patella-related complications. However, our study showed no differences between the designs at 1 year.

Stemmed Tibial Fixation for Primary Total Knee Arthroplasty in Obese Patients-A National Registry Study.

BACKGROUND: We investigated if the use of augmented tibial fixation with stems in primary total knee arthroplasty (TKA) in obese patients was associated with a difference in reason for revision, type of revision, or overall revision rate. METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry compared reason for revision, rate, and type of revision between primary TKA using stemmed tibial prostheses to nonstemmed prostheses, stratified by body mass index (BMI) and obesity. The cumulative percent revision was obtained using the Kaplan-Meier method, and Cox proportional hazards models estimated hazard ratios (HRs) adjusted for age and sex with 95% confidence intervals (CIs). All tests were 2-tailed at 5% statistical significance (P < .05). There were 66,508 procedures available for analyses. RESULTS: Obese class 2 (BMI 35 to 39.99) had higher rates of revision in the stemmed group compared to the nonstemmed group (HR 1.44, 95% CI 1.00, 2.05, P = .047). There was no significant difference in revision rates between stemmed and nonstemmed tibial prostheses in any other BMI group. Primary TKA in obese patients (BMI ≥30) with a stem extension had a significantly higher rate of minor revisions compared to no stem extension (HR 1.31, 95% CI 1.03, 1.66, P = .025). There was no significant difference between stemmed and nonstemmed groups for major revision in obese patients and for minor or major revision in nonobese patients. CONCLUSION: Using a tibial stem during primary TKA in obese patients is not associated with a lower rate of revision.

The Clinical Frailty Scale is a Strong Predictor of 1-Year Mortality in Surgically Managed Hip Periprosthetic Fracture: An Analysis From a High-Volume Institution.

BACKGROUND: Hip periprosthetic fractures (PPFs) after primary total hip arthroplasty are increasing with the number of primary implants and aging population. Mortality has been reported up to 34% at 1-year. The aim of this study was to evaluate the association of Clinical Frailty Scale (CFS) and 1-year mortality, complication rate, and length of stay (LOS) in surgically managed hip PPFs. METHODS: This was a retrospective study of prospectively collected data from January 2008 to January 2021. A total of 282 surgically managed hip PPFs were identified. Mean age was 79 years (range, 42 to 106). Preoperative scores were analyzed through linear regression to identify significant association with mortality, complication and LOS. Receiver operating characteristic curve and Area Under the Curve (AUC) were generated to evaluate the quality of the models and the discriminatory ability of each clinical score. Significance was considered at P values < .05. RESULTS: Mortality was 7.8% at 3-months and 15.7% at 1-year. Complication rate requiring surgery was 19.5% and mean LOS was 8.9 ± 7 days. The CFS was significantly associated with 3-month (odds ratio 2.23, P < .001) and 1-year mortality (odds ratio 2.01, P < .001). The receiver operating characteristic curve test for 1-year mortality showed a greater AUC for the CFS when compared with American Society for Anesthesiologists score and age-adjusted Charlson Comorbidity Index (AUC 0.80 versus 0.68 versus 0.72, respectively). CONCLUSIONS: Frailty is a syndrome with increased risk of mortality after surgically managed PPF. The CFS can be easily assessed at the time of admission and could be considered as a strong and reliable predictor of 1-year mortality with a greater AUC than the conventionally used American Society for Anesthesiologists score.

Utilizing Stems in Primary Total Knee Arthroplasty: Analysis of the Australian Orthopaedic Association National Joint Replacement Registry Data.

BACKGROUND: We compared revision rates and reasons for revision for primary total knee arthroplasty (TKA) performed for osteoarthritis with and without tibial stem extensions. METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry were used to compare all-cause revision, reason, and type of revision between primary TKA using stemmed tibial prostheses and non-stemmed prostheses. RESULTS: All-cause revision for TKA with stem extension was higher for the first 6 months (hazard ratio [HR] 1.47; 95% confidence interval [CI]1.19 to 1.82; P < .001); while after 1.5 years TKA with stem extension had a lower rate of revision (HR 0.84; 95% CI 0.73 to 0.97; P = .01). Stemmed components were more likely to be revised for infection between 3 months and 1.5 years after surgery (HR 1.39; 95% CI 1.05 to 1.83; P = .02). The revision rate for aseptic loosening was lower in the stemmed group beyond 2 years (HR = 0.45; 95% CI 0.31 to 0.63; P < .001). Insert-only revision was higher in the stemmed group at all times (HR = 1.42; 95% CI 1.21 to 1.66, P < .001). Isolated tibial component revision was lower in the stemmed group at all times (HR 0.47; 95% CI 0.29 to 0.74; P = .001). Aseptic loosening for tibial component-only revision was significantly lower in the stemmed group at all times (HR 0.23; 95% CI 0.11 to 0.50; P < .001). CONCLUSIONS: Patients undergoing primary stemmed TKA have lower rates of all-cause revision beyond 1.5 years and tibial component-only revision at all times. Further investigation is required to preoperatively select patients that benefit from augmentation with stems.

What are the Outcomes of Secondary Patella Resurfacing for Dissatisfaction Following Primary Knee Arthroplasty? A Systematic Review and Meta-Analysis of 604 Knees.

BACKGROUND: Secondary patella resurfacing is often performed for dissatisfaction following primary knee arthroplasty where the native patella was retained. The purpose of this meta-analysis was to evaluate outcomes of secondary patella resurfacing. METHODS: The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting on patients who underwent secondary patella resurfacing after previous primary knee arthroplasty with retention of the native patella were considered eligible. The risk of bias was assessed using the Methodological Index for Non-Randomized studies tool. A random-effects model and the inverse-variance weighting method was used for meta-analysis. There were sixteen retrospective studies including 604 knees (594 patients) with a mean follow up of 42 months (range, 2 to 197). RESULTS: An overall improvement in patient-reported outcomes (PROMs) was achieved in 53% of cases from pooled data available for 293 knees [95% Confidence Interval (CI) (0.44, 0.62), I2=68% - moderate heterogeneity]. The pooled proportion of patients satisfied with the procedure was 59% [95% CI (48, 68), I2 = 70% - moderate heterogeneity] in a sample size of 415. There was a minimal rate (2%) of complication incidence when performing secondary patella resurfacing and a pooled rate of revision surgery of 10%. CONCLUSIONS: An improvement in pain, satisfaction, and PROMs was achieved in slightly more than half of the patients following secondary patella resurfacing. However, studies lacked standardized objective selection criteria for the procedure and the available data was predominantly retrospective, with high heterogeneity and variation in outcome reporting.

Application of bone cement directly to the implant in primary total knee arthroplasty. Short-term radiological and clinical follow-up of two different cementing techniques.

PURPOSE: This study aimed to optimize cement application techniques in fully cemented primary total knee arthroplasty (TKA) by comparing the effects of two different approaches: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term presence of radiolucent lines (RLL) as indicators of potential complications. METHODS: In this monocentric study, a total of 379 fully cemented primary TKAs (318 patients) were included. The two study groups were differentiated by the technique of cement application: CoB group (cement applied only on bone surface) and CoBaI group (cement applied on both bone surface and implant surface). The presence of RLL or osteolysis was evaluated using the updated Knee Society Radiographic Evaluation System. RESULTS: In the whole study population, RLL were present in 4.7% of cases, with a significantly higher incidence in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up, RLL were observed in 29.8% of TKAs in the CoBaI group, while the incidence was lower in the CoB group (24.0%) (not statistically significant). There were two revisions in each group, none of which were due to aseptic loosening. CONCLUSION: The findings of this study suggest that the application of bone cement on bone surface only (CoB) may be more beneficial than applying it on both bone surface and implant surface (CoBaI) in terms of short-term presence of RLL in fully cemented primary TKA. Long-term results, especially with regard to aseptic loosening, will be of interest and may provide valuable guidance for future directions in bone cement applications in TKA.

Journey-Deuce bicompartmental knee arthroplasty with the addition of computer navigation achieves good clinical outcomes and implant survival at 10 years.

PURPOSE: To report 10-year outcomes and survivorship in patients undergoing bicompartmental knee arthroplasty (BCKA) using the Journey-Deuce prosthesis in a consecutive prospective case series. METHODS: Between November 2006 and November 2009, 41 patients with a mean age of 69.6 years (range 51-86) underwent 51 bicompartmental knee arthroplasties with the Journey-Deuce knee prosthesis. All patients presented with symptomatic medial and patellofemoral compartment osteoarthritis, with intact cruciate ligaments and a preserved lateral compartment on plain radiographs and Magnetic Resonance Imaging. Clinical assessment was undertaken pre-surgery and at 1, 2, 5 and 10 years post-surgery using the Oxford Knee Score (OKS), EuroQol Group 5-Dimension self-reported questionnaire (EQ-5D) and maximal active range of motion (ROM). RESULTS: 30 patients (37 knees) were followed-up at a mean time of 11.4 years (SD 1.1; range 10.5-14.0). Eight patients (ten knees) were deceased and three could not be contacted at final review. No major component revision was performed. Pre-operative OKS 25.4 (SD 5.2; range 15-40), knee flexion 116.4° (SD 10.3°; range 100°-140°) and EQ-5D 70.5 (SD 19.9; range 25-95). 10-year OKS 43.5 (SD 4.1; range 32-48), knee flexion 127.3° (SD 11.1°; range 105°-144°) and EQ-5D 77.4 (SD 9.3; range 60-100). The OKS (p < 0.0001), EQ-5D (p = 0.024) and active knee flexion ROM (p < 0.0001) all significantly improved from pre-surgery to 1-year post-surgery, with no further significant changes in these scores between any post-operative time period up until 10 years. 32% (7/22) of tibial and 45% (10/22) of femoral components showed progressive radiolucencies between 2 and 5-year and 10-year follow-up. CONCLUSIONS: This is the largest cohort of patients having undergone BCKA (with the Journey-Deuce prosthesis) with longest follow-up described in the literature. At 10 years, patients presented with significantly improved clinical outcomes, comparable to other surgical arthroplasty options. No major component revision was performed. Progressive radiolucencies were noted in 32% of tibial and 45% of femoral components without corresponding clinical signs of loosening. LEVEL OF EVIDENCE: Level III.

Obesity, Comorbidities, and Prior Operations Additively Increase Failure in 2-Stage Revision Total Knee Arthroplasty for Prosthetic Joint Infection.

BACKGROUND: Prosthetic joint infection (PJI) of the knee carries significant morbidity, mortality, and economic cost. We hypothesize that obese and poor medical hosts will have a significant and additive increase in failure rate undergoing 2-stage revision total knee arthroplasty for PJI. METHODS: All 2-stage revision total knee arthroplasty procedures for PJI performed at one institution were identified between 2005 and 2020. In total, 144 patients were included and defined as success or failure based on published criteria regarding infection eradication, further intervention, or mortality. The American Society of Anesthesiologists score and the Charlson Comorbidity Index were utilized to assess host grade. Patient, surgical, and microbiologic variables were investigated with univariable and multivariable analysis to explore association with risk of failure. RESULTS: In the cohort, 32.4% of patients failed with mean follow-up of 5.1 years. In multivariable analysis, the number of major operations requiring arthrotomy and implantation of new material between the primary and first stage, host grade, and elevated body mass index were the major contributors to failure. Combining these factors, with body mass index >30 and 2 or more major operations, the failure rate increased to 76.5% and 71.4% respectively for American Society of Anesthesiologists score 3 (P ≤ .001) and Charlson Comorbidity Index ≥2 (P ≤ .001). CONCLUSION: In this cohort, multiple major operations between the primary and first stage, host grade, and obesity were the major contributors to failure. When combining these factors, patients had an additive increase in failure rate. Treatments such as amputation or less invasive options and suppression should be discussed and considered in these patients.

A non-randomised pragmatic trial for the early detection and prevention of surgical wound complications using an advanced hydropolymer wound dressing and smartphone technology: The EDISON trial protocol.

Total hip or knee arthroplasty is a highly effective intervention for treating the symptoms of degenerative joint disease or osteoarthritis (OA), often an unwelcome consequence of obesity. A safe and common surgical procedure, hip and knee arthroplasty procedures are not immune to the occurrence of postoperative complications such as surgical site infection (SSI) or surgical wound dehiscence (SWD). While published rates of SSI following hip or knee arthroplasty are low, 1% to 2% in some cases, it is the resulting wound complication and its clinical management and the impact on patient well-being and return to daily life for the 1% to 2% that is of concern. Postoperative complications such as SSI are a major cost driver to the health care system following arthroplasty and often result in extended lengths of stay, readmission for further surgery, primary and community nursing visits, and are a costly burden to health care settings. Early identification of a wound complication through post-discharge surveillance using a fully transparent dressing and smartphone technology and patient education may ameliorate contributing factors or reduce the likelihood of a complication occurring in the first instance. This clinical trial is a non-randomised pragmatic convenience sample carried out in 200 participants of both sexes receiving either a TKA or THA. There will be equal allocation to two groups (100 hips and 100 knees), with 50 in each allocation receiving the interventional dressing and 50 as control. The dressing will be applied prior to discharge and participants will be provided with education on postoperative wound care, when to contact home care nursing for a potential wound problem, and use of their smartphone to capture and send images of their incision site to the study nurses. Participants will also be followed up by home care nursing services at day 14 for suture removal and wound assessment. Participants will complete a patient-reported outcomes survey on day 14 and followed up on day 30 after surgery for wound assessment. The results of this trial may provide a novel pathway using a fully transparent dressing and digital technologies for the prevention of acute readmissions because of wound complications through early detection and intervention.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

Osteoarthritis is associated with increased failure of proximal femoral fracture fixation.

PURPOSE: The purpose of this study was to evaluate whether the presence of hip osteoarthritis at the time of hip fracture increases treatment failure rates when using either a sliding hip screw (SHS) or proximal femoral nail (PFN) for fracture fixation. METHODS: A retrospective study of a consecutive series of 455 women and 148 men (median age, 83.8 years) treated with SHS or PFN was performed. Osteoarthritis was evaluated based on pre-operative radiographs using the Kellgren and Lawrence grading system. Treatment failure, which was defined as non-union, avascular necrosis, backing out of the implant, cut out of the proximal screws, peri-prosthetic fracture, implant breakage, or conversion to hemi- or total hip arthroplasty, was evaluated for a follow-up period of four to seven years. Optimal placement of the implant (tip-apex distance (TAD) and 3-point fixation) and the effects of age, sex, the quality of reduction, implant type, fracture stability, fracture type, and time to failure were considered confounders of the relationship between failure and osteoarthritis (OA). RESULTS: Among the 32 cases (5.3%) of treatment failure, 12 (2%) showed evidence of osteoarthritis. After controlling for age, sex, the quality of reduction, implant type, fracture stability, fracture type, and TAD, osteoarthritis was associated a greater than threefold increase in treatment failure compared with that of patients without pre-operative evidence of osteoarthritis (OR, 3.26; 95% CI, 1.4-7.65; P = 0.006). CONCLUSIONS: After adjusting for potential confounding factors, radiographic evidence of hip osteoarthritis at the time of hip fracture increases the incidence of treatment failure.

Wound Discharge After Pharmacological Thromboprophylaxis in Lower Limb Arthroplasty.

BACKGROUND: The benefits vs risk of pharmacological prophylaxis for thromboembolic disease in orthopedic patients remain controversial. Pharmacological thromboprophylaxis regimes are commonly used in this patient group. Few studies specifically examine wound complications attributable to this therapy. In this prospective trial, we investigated the effect of various regimens on postoperative wounds. METHODS: A prospective, observational, multicenter study involving patients undergoing elective hip or knee arthroplasty was undertaken. Patients were divided into 3 groups depending on thromboprophylaxis: no anticoagulation, aspirin, or low molecular weight heparin (LMWH) (enoxaparin). Surgical wounds were evaluated for each regime using the Southampton Wound Assessment Score. RESULTS: Over a 12-month period, 327 patients were enrolled with a mean age of 68.1 years (±11.2 years). There were 105 patients in the no anticoagulation group (32.1%), 97 patients in the aspirin group (29.7%), and 125 patients in the LMWH group (38.2%). Wound scores were evaluated for evidence and amount of discharge. The use of LMWH conferred a 4.92 times greater risk and aspirin a 3.64 times greater risk of wound discharge than no pharmacological thromboprophylaxis (P < .0001). There were no significant differences in the incidence of deep vein thrombosis or pulmonary embolus between groups either as an inpatient or postdischarge. CONCLUSION: There is a significant increase in the risk of wound discharge when aspirin or LMWH is used in arthroplasty patients. As potential complications of wound problems are significant, a more balanced view of risk vs benefit needs to be taken when prescribing thromboprophylaxis for this patient group.

Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty.

BACKGROUND: To determine the effect of mobilization on the day of surgery on the readiness for discharge and length of stay after elective total hip arthroplasty (THA). METHODS: We devised a randomized control trial with concealed allocation and intention-to-treat analysis. Overall, 126 patients who underwent THA and met the criteria for mobilization on the day of surgery were randomly allocated into 2 groups; the intervention group was mobilized on the day of surgery, n = 58 and the control group was mobilized on the day after surgery, n = 68. Apart from timing of mobilization, both groups received the same postoperative management. The primary outcome measures were length of hospital stay and time to readiness for discharge. RESULTS: The early mobilization group was ready for discharge 63 hours (standard deviation [SD] = 15 hours) after surgery, compared to 70 hours (SD = 18 hours) for the control group (P = .03, 95% CI, 0.7-12.8). There was no significant difference in hospital stay in the early mobilization group (77 hours [SD = 30 hours]), compared to the control group (87 hours [SD = 35 hours]; P = .11, 95% CI, -2.1 to 21.6). Despite this at any point in time after the surgery, the intervention group was 1.8 times (P = .003, 95% CI, = 1.2-2.7) more likely to have been discharged. CONCLUSION: Mobilization on the day of THA surgery significantly increases the probability of discharge at any singular point in time compared with mobilization on the day after surgery and decreases the time to readiness for discharge.

Better Axial Stiffness of a Bicortical Screw Construct Compared to a Cable Construct for Comminuted Vancouver B1 Proximal Femoral Fractures.

The aim of this study was to biomechanically evaluate the Locking attachment plate (LAP) construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty. Each construct incorporated a locking compression plate with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bi-cortical locking screws. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (P=0.01). The LAP construct offers better axial stiffness compared to the cable construct in the fixation of comminuted Vancouver B1 proximal femoral fractures.

Development of a scale to assess performance following primary total knee arthroplasty.

BACKGROUND: Quantitative assessment of postsurgical knee motion provides sensitive measurements, but results are technical and may not be meaningful to patients. Although several knee-specific instruments exist, no patient-reported outcome (PRO) measure correlates function with improved stability, motion, satisfaction, and confidence. OBJECTIVE: To address both the above limitations by developing a PRO measure to assess the phenomenon of a "normal" knee after primary total knee arthroplasty (TKA). METHODS: A draft conceptual model linking the impact of clinical mechanics to hypothesized functional outcomes was generated after a literature review of available assessment tools. Participants aged 18 to 80 years having undergone TKA within the past 10 to 18 months were identified and screened by clinical sites to participate in phase 1 focus groups or phase 2 in-depth interviews. Participants were asked to describe their TKA experiences, including how their knee feels now, followed by cognitive debriefing of Patient's Knee Implant Performance (PKIP) draft items. RESULTS: Phase 1 results indicated that concepts of confidence, stability, and satisfaction in patients' replacement knee when performing certain activities were distinct and important in the patients' assessment of their TKA. Phase 2 efforts yielded a final version of the PKIP measure containing nine items assessing the broader concepts of stability, confidence, and satisfaction in association with activities. Presurgical and postsurgical versions of the measure were created. CONCLUSIONS: Results of this qualitative study support use of the PKIP as a complementary PRO measure to assess performance after primary TKA. Psychometric evaluation of the PKIP is planned.

Predictors of perioperative blood transfusions in patients with chronic kidney disease undergoing elective knee and hip arthroplasty.

BACKGROUND: Lower preoperative haemoglobin and older age pose a risk for perioperative allogeneic blood transfusions (ABT). The presence of chronic kidney disease (CKD) is associated with low haemoglobin, greater bleeding and ABT utilization. STUDY DESIGN AND METHODS: The interaction between estimated glomerular filtration rate (eGFR) and haemoglobin on perioperative ABT, length-of-stay and mortality was assessed in 86 patients with CKD stage 3 or higher undergoing elective total knee or hip arthroplasty compared with 294 without CKD. Multivariate analyses for ABT risk with haemoglobin, eGFR, age, gender, duration of surgery and primary versus revision surgery were performed. RESULTS: Patients with CKD had lower preoperative haemoglobin and higher incidence of ABT. Haemoglobin was independently associated with increased odds of ABT (0.74 (95% confidence interval 0.71-0.77), P = 0.001), but eGFR was not (0.98 (0.96-1.02), P = 0.089). Length-of-stay and 1 year mortality did not differ between non-transfused CKD patients and controls. Transfused CKD patients had significantly higher length-of-stay compared with transfused controls (25 ± 21 vs 19 ± 16 days, P < 0.0001), although 1 year mortality between transfused CKD patients and controls did not differ significantly. CONCLUSION: CKD alone, in the absence of anaemia, does not predispose to increased risk of ABT or length-of-stay in patients with mild-to-moderate CKD undergoing elective joint surgery. However, low haemoglobin is associated with increased ABT utilization and increased length-of-stay. Considering that 1 in 4 patients undergoing elective hip or knee arthroplasty has CKD, optimal preoperative patient blood management may improve outcome in this population.

Can plate osteosynthesis of periprosthethic femoral fractures cause cement mantle failure around a stable hip stem? A biomechanical analysis.

Periprosthetic femoral fractures (PFF) are a serious complication after total hip arthroplasty. Plate fixation with screws perforating the cement mantle is a common treatment option. The study objective was to investigate hip stem stability and cement mantle integrity under dynamic loading. A cemented hip stem was implanted in 17 composite femur models. Nine bone models were osteotomised just distal to the stem and fixed with a polyaxial locking plate the other eight constructs served as the control group. All specimens were tested in a bi-axial material testing machine (100000 cycles). There were no statistically significant differences in axial nor in medial (varus) stem migration. No cement cracks were detected in both groups. Plate fixation of a PFF with a stable, cemented prosthesis did not lead to cement mantle failure in this in vitro study.

High failure rates of the Spectron EF stem at a minimum of 10 year's follow-up.

We prospectively followed 112 hips, undergoing THA with a Spectron EF stem. At mean follow-up of 11.2years, 21 patients had died. We obtained radiological follow-up in 99% and clinical follow-up in 100% of the surviving 91 hips. Fifty-four percent demonstrated osteolysis in at least one Gruen zone. Twenty-two hips required revision for all causes, with a further five stems radiologically loose. With endpoint being stem revision for aseptic loosening or radiological failure, survivorship at 11years was 0.783. We believe the addition of a rougher surface finish has contributed to the high levels of osteolysis and stem failure seen with the Spectron EF.