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1.
Comparison of postoperative effectiveness of less invasive short external rotator sparing approach versus standard posterior approach for total hip arthroplasty.
Wang, T, Zhou, Y, Li, X, Gao, S, Yang, Q
Journal of orthopaedic surgery and research. 2021;(1):46
Abstract
BACKGROUND Most of the studies assessing the corrective posterior total hip arthroplasty (THA) mainly focused on the mini-incision approach. Studies exploring the short external rotator sparing approach are rare. Therefore, this study aimed to compare the effectiveness of standard posterior approach and short external rotator sparing approach. METHODS This prospective observational study included 126 patients who underwent THA in June 2017-June 2018. Patients were assigned to standard (standard posterior approach) and corrective (short external rotator sparing approach) groups based on the surgical method. Surgical data were recorded postoperatively. Postoperative hip joint recovery was assessed using the times to ambulation and independent stair use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Harris score, and Oxford hip score (OHS) at 2 and 8 postoperative weeks. The visual analog scale (VAS) was used for postoperative pain assessment. RESULTS Postoperative changes of creatine kinase (CK), myoglobin, CRP, and prosthesis position were similar in both groups (P > 0.05). However, intraoperative blood loss (P < 0.001) and postoperative 6-h drainage volume (P = 0.03), hospital stay, blood transfusion rate, and times to ambulation and independent stair use were significantly reduced in the corrective group. Postoperatively, Oxford, and WOMAC scores significantly decreased in both groups. After surgery, the VAS score was more overtly decreased in the corrective group compared with the standard group. CONCLUSIONS This study concluded that the less invasive short external rotator sparing approach for THA caused less damage, reducing perioperative blood loss, shortening functional recovery time, maintaining prosthesis stability, and improving postoperative pain.
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Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers.
Abad-Motos, A, Ripollés-Melchor, J, Jericó, C, Basora, M, Aldecoa, C, Cabellos-Olivares, M, Navarro-Pérez, R, Bisbe, E, García-Erce, JA
Revista espanola de anestesiologia y reanimacion. 2020;(5):237-244
Abstract
BACKGROUND Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. OBJECTIVES AND METHODS We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). RESULTS A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy. CONCLUSIONS The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.
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Is postoperative hyponatremia a real threat for total hip and knee arthroplasty surgery?
Sinno, E, De Meo, D, Cavallo, AU, Petriello, L, Ferraro, D, Fornara, G, Persiani, P, Villani, C
Medicine. 2020;(20):e20365
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Abstract
Postoperative hyponatremia (POH) is thought to be a fearsome complication of orthopedic surgery. Primary aim of this cohort study was to evaluate the incidence of POH and its clinical relevance in elective surgery, outlining differences between total knee arthroplasty (TKA) and total hip arthroplasty, looking for the presence of any risk factor commonly related to POH.Four hundred two patients that underwent total hip arthroplasty and total knee arthroplasty performed between 2016 and 2017 were retrospectively examined. Serum electrolytes, hemoglobin, hematocrit, glucose, and creatinine were evaluated preoperatively and at day 0-I-II from surgery. Age, sex, body mass index, comorbidities, drugs, surgery data, transfusions, postoperative symptoms, and length of stay (LOS) were determined. All surgeries were performed by the same equipe. Patients had the same perioperative management, excluded those that took thiazides, already at risk of POH.Patients were divided in 2 groups: group A, patients with normal postoperative natremia (294 patients) and group B, patients who developed POH (108, 26.9%); 66.7% of these developed POH within 24 hours postoperatively. In group B mean postoperative natremia was 133.38 (127.78-134.85) mmol/L. Two patients (1.8%) developed moderate hyponatremia, no severe hyponatremia was documented. Type of surgery, operation time, LOS, and presence of postoperative symptoms did not show statistically significant differences within groups. At multivariate logistic analysis chronic use of thiazides was the only variable associated to a decreased risk of developing POH (OR = 0.39; P = .03). Hemoglobin postoperative values (OR = 1.22; P = .03), the need of postoperative transfusion (OR = 2.50; P = .02) and diabetes (OR = 2.70; P = .01) were associated to an increased risk of POH.Although 26.9% of our patients exhibited POH, the onset of this disorder had no implication on postoperative symptoms and on LOS. Diabetes and transfusion are factors most often associated to POH.
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Exploring variation in patient access of post-discharge physiotherapy following total hip and knee arthroplasty under a choice based system in the UK: an observational cohort study.
Hamilton, DF, Loth, FC, MacDonald, DJ, MacFarlane, GJ, Beard, DJ, Simpson, AHR, Patton, JT, Howie, CR
BMJ open. 2019;(2):e021614
Abstract
OBJECTIVES To assess a targeted 'therapy as required' model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether accessing therapy was associated with post-arthroplasty patient reported outcomes and whether it was possible to predict which patients would access post-discharge physiotherapy from pre-operative data. DESIGN Prospective, observational, longitudinal cohort study. SETTING Single National Health Service orthopaedic teaching hospital in the UK. PARTICIPANTS 1395 patients undergoing total hip arthroplasty and 1374 patients undergoing total knee arthroplasty. PRIMARY AND SECONDARY OUTCOME MEASURES Self-reported access of post-discharge physiotherapy, the Oxford Hip or Knee Score, EuroQol 5-dimension questionnaire and post-operative surgical episode satisfaction metric. RESULTS 662 (48.2%) patients with TKA and 493 (35.3%) patients with THA accessed additional post-discharge physiotherapy. Patient-reported outcomes (p<0.001) and surgical episode satisfaction (p=0.001) in both THA and TKA were higher in patients that did not participate in post-discharge physiotherapy. Regression models using pre-operative symptom burden and demographic data predicted post-discharge therapy access with an accuracy of only 17% greater than chance in patients with THA and 7% greater than chance in patients with TKA. CONCLUSIONS In a choice-based service model of 'therapy as required' following hip and knee arthroplasty only a third of THA and half of TKA patients accessed post-discharge therapy. Patients who did not access physiotherapy reported greater post-operative outcomes. This variation in the need for post-discharge physiotherapy suggests that targeting of rehabilitation may be a cost-effective model, however it was not possible to reliably predict which patients would access post-discharge physiotherapy from pre-operative data.
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Thromboembolic and major bleeding events in relation to perioperative bridging of vitamin K antagonists in 649 fast-track total hip and knee arthroplasties.
Jørgensen, CC, Kehlet, H, ,
Acta orthopaedica. 2017;(1):55-61
Abstract
Background - The benefit of preoperative bridging in surgical patients with continuous anticoagulant therapy is debatable, and drawing of meaningful conclusions may have been limited by mixed procedures with different thromboembolic and bleeding risks in most published studies. Patients and methods - This was an observational cohort treatment study in consecutive primary unilateral total hip and knee arthroplasty patients between January 2010 and November 2013 in 8 Danish fast-track departments. Data were collected prospectively on preoperative comorbidity and anticoagulants in patients with preoperative vitamin K antagonist (VKA) treatment. We performed 30-day follow-up on in-hospital complications and re-admissions through the Danish National Patient Registry and patient records. Results - Of 13,375 procedures, 649 (4.7%) were in VKA patients with a mean age of 73 (SD 9) years and a median length of stay of 3 days (IQR: 2-4). Preoperative bridging was used in 430 (67%), while 215 (33%) were paused. Of 4 arterial thromboembolic events (ATEs) (0.6%), 2 were in paused patients and 2 were in bridged patients (p = 0.6). Of 3 venous thromboembolic events (VTEs) (0.5%), 2 were in paused patients and 1 was in a bridged patient (p = 0.3). Of 8 major bleedings (MBs) (1.2%), 1 was in a paused patient and 7 were in bridged patients (p = 0.3), 5 of whom received therapeutic bridging. Similar results were found in a propensity-matched cohort. Interpretation - In contrast to recent studies in mixed surgical procedures, no statistically significant differences in ATE, VTE, or MB were found between preoperative bridging and pausation of VKA patients. However, the higher number of thromboembolic events in paused patients and the higher number of major bleedings in bridged patients warrant more extensive investigation.
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3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement.
Sillesen, NH, Greene, ME, Nebergall, AK, Huddleston, JI, Emerson, R, Gebuhr, P, Troelsen, A, Malchau, H
Hip international : the journal of clinical and experimental research on hip pathology and therapy. 2016;(1):97-103
Abstract
PURPOSE Preclinical studies of vitamin E diffused highly cross-linked polyethylene (E-XLPE) has shown enhanced mechanical properties with less wear. The purpose of our study was to document the early clinical outcome of E-XLPE to ensure, for the safety of patients, that there are no unforeseen early adverse events from using this new biomaterial. METHODS The enrolled patients (n = 977) have received either a porous titanium coated or porous plasma sprayed acetabular shell with either a E-XLPE liner or a medium cross-linked (AXL) liner. At each follow-up 5 patient-reported outcome measures (PROMs) were completed: Harris Hip Score, Case Mix Indicator, UCLA Activity Score, SF-36, and EQ-5D. Radiographs were measured for cup and stem position, as well as femoral head penetration into the liner (wear). Postoperative complications and revisions were collected. RESULTS At 3 years follow-up, there were 13 revisions due to: 4 periprosthetic fractures; 1 sepsis; 6 instabilities; and 2 implant mismatches at surgery. Wear of the hip implant, calculated by software analysis of pelvis x-rays, from the postoperative interval to 3 years showed a liner penetration rate of 0.027 mm/year for AXL and 0.005 mm/year for E-XLPE with no significant difference between the 2 (p = 0.24). Improvement was seen in all PROMs from the preoperative interval to 3 years after surgery (p<0.0001). CONCLUSIONS Early follow-up of the E-XLPE and AXL liners show low penetration. PROMs indicate improvement after total hip arthroplasty in functionality and quality of life across the centers. We have not observed any early in vivo adverse effects from diffusing the liners with vitamin E. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00545285.
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Wintertime surgery increases the risk of conversion to hip arthroplasty after internal fixation of femoral neck fracture.
Sebestyén, A, Mester, S, Vokó, Z, Gajdácsi, J, Cserháti, P, Speer, G, Patczai, B, Warta, V, Bódis, J, Horváth, C, et al
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2015;(3):1109-17
Abstract
UNLABELLED The study demonstrates that wintertime surgeries are associated with impaired fracture healing and increases the risk of conversion to hip arthroplasty after osteosynthesis of femoral neck fracture. Furthermore, the results raise the possibility of association between seasonal changes in vitamin D levels and impaired fracture healing of femoral neck fracture. INTRODUCTION Although the changes of vitamin D level and calcitropic hormones influencing bone metabolism are seasonal, the effect of seasons on hip fracture healing is unknown. We assessed the effects of seasonal periodicity on conversion to hip arthroplasty after primary osteosynthesis of femoral neck fracture. METHODS This nationwide retrospective observational cohort study involved 2779 patients aged ≥ 60 years who underwent internal screw fixation for primary femoral neck fracture and were discharged in 2000. Cases requiring conversion to arthroplasty during the 8-year follow-up derived from the Hungarian health insurance database were registered. Risk factors assessed included sex, age, fracture type, season of primary surgery and surgical delay. Competing-risks regression analysis was used for data analyses. RESULTS During the observation period, 190 conversions to hip arthroplasty (6.8%) were identified, yielding an overall incidence of 19.5 per 1000 person-years. The crude incidence rates of conversions after osteosynthesis in winter, spring, summer and fall were 28.6, 17.8, 16.9 and 14.7 per 1000 person-years, respectively. Besides younger age, female sex and intracapsular fracture displacement, wintertime primary osteosynthesis significantly increased the risk of conversion (fall vs. winter, hazard ratio (HR): 0.50, 95% confidence interval [95% CI 0.33-0.76]; spring vs. winter, HR: 0.63, [95% CI 0.44-0.92]; summer vs. winter, HR: 0.62, [95% CI 0.42-0.91]). CONCLUSIONS Our study demonstrate that wintertime primary osteosynthesis increases the risk of conversion surgeries. The results may help improving the outcome of primary fixation of femoral neck fractures.
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Three Year RSA Evaluation of Vitamin E Diffused Highly Cross-linked Polyethylene Liners and Cup Stability.
Sillesen, NH, Greene, ME, Nebergall, AK, Nielsen, PT, Laursen, MB, Troelsen, A, Malchau, H
The Journal of arthroplasty. 2015;(7):1260-4
Abstract
Vitamin E diffusion into highly cross-linked polyethylene (E-XLPE) is a method for enhancing oxidative stability of acetabular liners. The purpose of this study was to evaluate in vivo penetration of E-XLPE using radiostereometric analysis (RSA). Eighty-four hips were recruited into a prospective 10-year RSA. This is the first evaluation of the multicenter cohort after 3-years. All patients received E-XLPE liners (E1, Biomet) and porous-titanium coated cups (Regenerex, Biomet). There was no difference (P=0.450) in median femoral head penetration into the E-XLPE liners at 3-years comparing cobalt-chrome heads (-0.028mm; inter-quartile range (IQR) - 0.065 to 0.047) with ceramic heads (-0.043mm, IQR - 0.143to0.042). The 3-year follow-up indicates minimal E-XLPE liner penetration regardless of head material and minimal early cup movement.