The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand across Scotland for primary hip and knee arthroplasty in the future. Understanding the scale of potential change to operative workflow is essential to ensure adequate provision of services, and prevent prolonged waiting times that can cause patient harm. We therefore set out to provide projections of future primary hip and knee arthroplasty out to 2038 utilising historical trend data (2008–2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age & sex group predictions were also performed. All results are presented per 100,000 population at-risk per year (/100k/year). The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 27% increase. The predicted rise of primary knee arthroplasty for all ages is from 164/100k/year in 2018 to 220/100k/year in 2038, a 34% increase. Based on a static 3 day length of stay average this would see 4280 additional patient bed days for hips, and 7392 for knees, required nationally per year by 2038. The associated supplementary cost to the NHS is anticipated to be around £21 million per annum. Knowledge of increasing resource utilisation and cost associated with predicted future demand for primary hip and knee arthroplasty provides key information for service organisation and delivery

Aims. The efficacy and safety of intrawound vancomycin for preventing surgical site infection in primary hip and knee arthroplasty is uncertain. Methods. A systematic review of the literature was conducted, indexed from inception to March 2020 in PubMed, Web of Science, Cochrane Library, Embase, and Google Scholar databases. All studies evaluating the efficacy and/or safety of intrawound vancomycin in patients who underwent primary hip and knee arthroplasty were included. Incidence of periprosthetic joint infection (PJI), superficial infection, aseptic wound complications, acute kidney injury, anaphylactic reaction, and ototoxicity were meta-analyzed. Results were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The quality of included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. Results. Nine studies involving 4,607 patients were included. Intrawound vancomycin was associated with lower incidence of PJI (30 patients (1.20%) vs 58 control patients (2.75%); OR 0.44, 95% CI 0.28 to 0.69) and simultaneous acute kidney injury (four patients (0.28%) vs four control patients (0.35%), OR 0.71, 95% CI 0.19 to 2.55). However, it did not reduce risk of superficial infection (four patients (0.67%) vs six control patients (1.60%), OR 0.60, 95% CI 0.17 to 2.12) and was associated with higher incidence of aseptic wound complications (23 patients (2.15%) vs eight in control patients (0.96%), OR 2.39, 95% CI 1.09 to 5.23). Four studies reported no anaphylactic reactions and three studies reported no ototoxicity in any patient group. Conclusion. The current literature suggests that intrawound vancomycin used in primary hip and knee arthroplasty may reduce incidence of PJI, but it may also increase risk of aseptic wound complications. Cite this article: Bone Joint Res 2020;9(11):778–788

Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR. Four interconnected work packages have recently been completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from four national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty. We will present the following Recommendations:. For ODEP10A∗ minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review. For ODEP10A∗ minimum implants in complex cases, or non-ODEP10A∗ minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years. At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation. After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment; ongoing rapid access to orthopaedic review is still required. Overarching statements. These recommendations apply to post primary hip and knee replacement follow-up. The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years. The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure

Introduction and Objective. Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study was to evaluate in a single Institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence. Materials and Methods. Surgical records were searched for PFFs around a primary hip stem from January 2013 to December 2019. Cases were classified according to Vancouver classification. Demographic and medical history were extracted. Fisher's exact test was used for statistical analysis. Results. One-hundred-fifteen PFFs were identified, 59 of them were type B1 and 16 were type C. Radiographs and medical records were available for all patients. Twenty-four patients (32%) have been treated with bisphosphonates (BPs) for longer than 4 years. Four patients presented a fracture with characteristics of PAFF. When enlarged to all PFFs of the series, no other PAFF was found: prevalence of PAFFs was 5.3% for type B1 and C cases and 3.5% for all surgically treated PFFs. Statistical significative difference between PAFFs and PFFs was found for prolonged BPs assumption and for the level of fracture clear of the stem. Conclusions. Fracture with characteristics of AFFs can also happen over a prosthetic stem, configuring themselves as PAFFs, and they are related to prolonged BPs use. As a correct diagnosis is mandatory for proper treatment, a revision of criteria for AFFs should be considered, accepting that PAFFs exist

Aim. To date, the value of culture results after a debridement, antibiotics and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At one year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIRs after primary total hip or knee arthroplasty. The secondary aim was to explore differences in patient characteristics, infection characteristics and outcomes between these two groups. Methods. A retrospective regional registry study was performed in a group of 359 patients (positive cultures: n = 299, negative cultures n = 60) undergoing DAIR for high suspicion of early PJI in the period from 2014 to 2019. Differences in patient characteristics, deceased patients and number of subsequent DAIRs between the positive and negative DAIR groups were analyzed using independent t-tests, Mann-Whitney, Pearson's Chi-square tests and Fisher's Exact tests. Results. Overall implant survival rate following DAIR was 89%. The relative risk for prosthesis removal was 7.4 times higher (95% confidence interval (CI) 1.0–53.1) in the positive DAIR group (37/299, 12.4%) compared to the negative DAIR group (1/60, 1.7%). The positive group had a higher body mass index (p = 0.034), rate of wound leakage of >10 days (p = 0.016) and more subsequent DAIRs (p = 0.006). Conclusion. Since implant survival results after DAIR are favorable, the threshold to perform a DAIR procedure in early PJI should be low in order to retain the prosthesis. A DAIR procedure in case of negative cultures does not seem to have unfavorable results in terms of prosthesis retention

Aims. Up to one in five patients undergoing primary total hip (THA) and knee arthroplasty (TKA) require contralateral surgery. This is frequently performed as a staged procedure. This study aimed to determine if outcomes, as determined by the Oxford Hip Score (OHS) and Knee Score (OKS) differed following second-side surgery. Methods. Over a five-year period all patients who underwent staged bilateral primary THA or TKA utilizing the same type of implants were studied. Eligible patients had both preoperative and one year Oxford scores and had their second procedure completed within a mean (2 SDs) of the primary surgery. Patient demographics, radiographs, and OHS and OKS were analyzed. Results. A total of 236 patients met the inclusion criteria, of which 122 were THAs and 114 TKAs. The mean age was 66.5 years (SD 9.4), with a 2:1 female:male ratio. THAs showed similar significant improvements in outcomes following first- and second-side surgery, regardless of sex. In contrast for TKAs, although male patients demonstrated the same pattern as the THAs, female TKAs displayed significantly less improvement in both OKS and its pain component following second-side surgery. Conclusion. Female patients undergoing second-side TKA showed less improvement in Oxford and pain scores compared to the first-side. This difference in outcome following second-side surgery did not apply to male patients undergoing TKA, or to either sex undergoing THA. Cite this article: Bone Jt Open 2021;2(4):243–254

Aims

To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty.

Objectives. Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties. Methods. A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group. Results. An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06). Conclusions. Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications. Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

Purpose. Case logs have been utilized as a means of assessing residents surgical exposure and involvement in cases. It can be argued that the degree of involvement in operative cases is as important as absolute number of cases logged. A log which contains accurate information on actual participation in surgical cases in addition to self reported competency, is a powerful tool in obtaining a true reflection of surgical experience. Thus a prerequisite for a valuable log is the ability to perform an accurate self-assessment. Numerous studies have shown mixed results when examining residents ability to perform self-assessment on varying tasks. The purpose of the study was to examine the correlation between residents self-assessment and staff surgeons evaluation of surgical involvement and competence in performing primary hip and knee arthroplasty surgery. Method. Self assessment data from 65 primary hip and knee arthroplasty cases involving 17 residents and 17 staff surgeons (93% response rate) was analyzed. Interobserver agreement between residents self perception and staff surgeons assessment of involvement was evaluated using the Intraclass Correlation Coefficient (ICC). An assessment of competency was performed utilizing a categorical global scale and evaluated with the Kappa statistic (k). Furthermore, a structured surgical skills assessment form was piloted as an objective appraisal of resident involvement and comparisons were made to resident and staff perception. Results. The Intraclass Correlation Coefficient for resident involvement between Resident and Staff was 0.80 (0.69–0.88) which represents substantial agreement between the groups. The agreement between resident and staff with regard to residents competency to perform case was k = 0.67 (0.50–0.84). The ICC for Resident, Staff, and Third Party observer utilizing the piloted skills assessment form was 0.82 (0.75–0.88) which represents substantial agreement and helps to confirm the agreement between various members of the surgical team. Conclusion. This study may help to confirm the ability of orthopaedic residents to perform a self-assessment of their degree of involvement and performance competency in primary hip and knee arthroplasty surgery. Furthermore, the staff surgeons assessment of resident involvement was highly correlated with the surgical skills assessment form. The inclusion of a self-assessment is a valuable addition to the surgical case log

Aim. Reveal the rate of surgical site infection (SSI) after primary hip and knee arthroplasty in patients with inflammatory joint disease and analyse if the infection rate was correlated to the given anti-rheumatic treatment. The background is that since 2006 patients operated at the orthopaedic department at Skåne University hospital, Lund, Sweden, have continued treatment with TNF-alpha inhibitors during the perioperative period. Method. During 2006 to 2015 494 planned primary hip and knee arthroplasties were performed on 395 patients (236 hip arthroplasties and 239 knee arthroplasties). Data on age, sex, diagnosis, BMI, operation time, ASA-classification, treatment with cDMARDs (conventional disease modifying anti-rheumatic drugs) and bDMARDs (biological disease modifying antirheumatic drugs) and use of prednisolone was collected. The primary outcome variable was prosthetic joint infection (PJI) within 1 year from surgery with a secondary outcome variable being superficial SSI. Results. In 32% (n=159) of the cases the patient was treated with a TNF-alpha inhibitor. The rate of PJI was 1.4% (n=7). The overall rate of infection, including superficial infections, was 2.4% (n=12). All the PJIs occurred after a knee arthroplasty and only 1 patient was treated with a TNF-alpha inhibitor (etanercept). Conclusions. We could not find that continuing treatment with TNF-inhibitors perioperatively led to a higher incidence of PJI or SSI than generally would be expected in a group of patients with an inflammatory joint disease. Based on these results there is no need to discontinue treatment with TNF-inhibitors when performing arthroplasty surgery

Purpose: The purpose of this work was to demonstrate the usefulness of osteoplasty block for the treatment of primary hip osteochondritis. Material and methods: Eighteen children underwent surgery between 1992 and 2001. Mean age at diagnosis was eight years five months (5–13 years). Preoperatively, mean motion limitation was −25 in abduction and internal rotation. Radiologically the series included: Catterall II Herring B with signs of high-risk head (n=2), III B (n=7), III C (n=1), IV B (n=1), IV C (n=2), and sequelar stage (n=2). Mean excentration was 6.5 mm and mean lateral overhang was 10.2 mm. Surgery was indicated because of an aggravation of the excentration with revascularisation. An iliac graft was encrusted in a limbic rail and covered with rectus femoris tendon left continuous to provide elastic support. A bermuda cast was used for 17 children with immediate weight bearing for eleven. Hospital stay was 36 hours for all children. Results: Sixteen children were reviewed at mean follow-up of three years two months. There were no complications. Clinically, there all patients were pain free, but three developed persistent limping. Ten had a moderate limitation of hip movement and three had severe joint stiffness. Radiologically, there was good head coverage in fifteen hips and joint congruency in fifteen, including eleven with concentric congruency. The intervention was considered useful for twelve children, and not useful for one who developed complete lysis of a poorly positioned graft. Usefulness was uncertain for three children, including the two with a sequelar-stage hip at diagnosis. Discussion: Femoral osteotomy to correct the valgus and pelvic osteotomy to reorient or widen the acetabulum are effective treatments but have many disadvantages (limited abduction movement, leg length discrepancy, re-intervention to remove material). The excellent integration of the plasty block at mid term is a sign of effective head-acetabulum adaptation. Clinical and radiological results have been similar to those obtained with other methods. Joint stiffness and postoperative limping are observed in very severe cases. Joint prognosis depends on the severity of the disease. Conclusion: This series of paediatric patients who have not yet reached bone maturity shows that the plasty block meets expectations for the treatment of early-stage primary hip osteochondritis. Treatment time is short and there are no complications

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times

The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products.

We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool.

We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present.

Introduction. Due to the opioid epidemic, our service developed a cultural change highlighted by decreasing discharge opioids after lower extremity arthroplasty. However, concern of potentially increasing refill requests exists. As such, the goal of this study was to analyze whether decreased discharge opioids led to increased postoperative opioid refills. Methods. We retrospectively reviewed 19,428 patients undergoing a primary hip or knee arthroplasty at a single institution from 2016–2019. Patients that underwent secondary procedures within that timeframe were excluded. Two-thousand two-hundred and forty-one patients (12%) were on narcotics preoperatively or had chronic pain syndrome. Two reductions in routine discharge narcotics were performed over this timeframe. First, 8,898 patients routinely received 750 morphine milligram equivalents (MMEs). After the first reduction, 4,842 patients routinely received 520 MMEs. After a second reduction, 5,688 patients routinely received 320 MMEs. We analyzed refill rates, refill MMEs, and whether discharge MMEs were associated with refill MMEs in a multivariate model. Results. Opioid refill rates were 28%, 32%, and 33% in each timeframe (p=0.001). Significantly fewer patients received narcotic refills after 6 weeks in the 320 MME group (8%) compared to the 750 MME group (6%, p=0.02). Total refill MMEs reduced significantly from a mean of 282 in the first to 227 in the last timeframe (p<0.001). After controlling for age, sex, BMI, history of anxiety/depression, and procedure type, opioid discharge of <400 MMEs was not a risk factor for increased refill MMEs in opioid-naïve patients (p=0.23). Conclusion. While decrease in MMEs prescribed at discharge after arthroplasty led to a slight increase in the number of opioid refills (5%), there was a reduction in total refill MMEs. Furthermore, less patients received refills beyond 6 weeks postoperatively. This institutional cultural change led to a reduction in opioid prescriptions after primary arthroplasty equivalent to 500,000 oxycodone 5 mg tablets

Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients.

A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge.

The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05).

Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level.

Retrospective review of consecutive arthroplasty cases performed at a District Hospital (DH), and a Tertiary Hospital (TH) in Cape Town, between January 2015 and December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts.

Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2±2.0 days at DH level and 7.6±7.1 days for TH (p<0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for TH (p<0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p<0.05). Death rate was 0.4% vs 0.6% at district and TH respectively (p>0.05). Periprosthetic joint infection rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at TH. During the study period, 228 patients received arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list.

Hip and Knee Arthroplasty at District health care level is safe and may help ease the burden on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures.

Primary hip and knee replacements can be associated with significant blood loss. Tranexamic acid is a fibrinolytic inhibitor that has been shown to significantly reduce blood loss and transfusion requirement in hip and knee replacement, however the cost-benefit has not been widely investigated. Our study involved 100 patients, comprising a prospective cohort of 50 consecutive primary hip and knee replacements (treatment group) and a control group of the preceding 50 patients undergoing the same surgery. All knee replacements were computer navigated. The prospective cohort all had tranexamic acid 1g intravenously at the time of surgery, repeated at 8 and 16 hours. All patients had 28 days thromboprophylaxis with subcutaneous low-molecular-weight-heparin. The control group comprised 24 hip replacements and 26 knees versus 17 hips and 33 knees in the treatment group. Autologous transfusion drains were used in the control group knee replacements and the mean volume reinfused was 458ml. These drains were only used in the first 15 knee replacements in the treatment group as only one patient drained enough for reinfusion (100ml; p< 0.001). The mean fall in haemoglobin in the control group post surgery was 3.4g/dl versus 2.3g/dl in the treatment group (p< 0.001). Seven patients were transfused in the control group (14 units of red cells) versus two in the treatment group (5 units). The potential cost saving per patient averaged across all joints in the treatment group is £102.51. This is a function of savings in transfusion, cessation of drains for re-infusion in knee replacement and the cost of tranexamic acid. The only thromboembolic event was 1 deep vein thrombosis in the treatment group. Our data shows the cost savings associated with the use of tranexamic acid in primary hip and knee surgery are considerable and supports its use to significantly reduce blood loss and transfusion requirement

To ascertain whether there is any relationship between the Oxford 12 scores gained six months post surgery and early revision for primary hip and knee arthroplasty. The six month post surgery Oxford 12 scores were retrieved from the National Joint Registry (NJR) for the seven year period ending 31. st. December 2006. These were analysed in relation to revision of primary hip and knee procedures using three methods of statistical analysis; logistic regression, receiver operating characteristic (ROC) curve and direct plotting of groups of scores against the proportion of hips revised for that same group. Logistic regression: For every one unit increase in the Oxford score there was an 11% increased risk of revision (hips) and 12% (knees) within the first two years of surgery, 5 and 6% respectively between two and four years and 3 and 4% risk respectively between four and six years (p> 0.001). The ROC Curve Analysis: demonstrated that a patient with a score greater than 20 (hips) or 28.5 (knees) or 24 (uni knees) has eight times the risk of needing a revision within two years compared to a person with a score equal or less than the above numbers. Alternatively the ROC analysis predicted 73% of the revisions within three years for all three arthroplasty groups. Plotting Scores Against Revisions: Plotting scores in groups of five demonstrated an incremental increase in the risk during the first two years. A person with a score greater than 40 has; for hips 24 times, knees 27 times and uni knees 69 times the risk of a revision within two years compared to a person with a score between 16 and 20. Monitoring of the six month post surgical Oxford 12 score is another tool in the surgeon’s armamentarium for deciding which patients need closer monitoring following arthroplasty surgery

Revision surgery is an important outcome of hip and knee arthroplasty among patients with osteoarthritis (OA). The objective of this study was to determine the risk of revision over time in a large, geographically defined population in North America, and to assess the effects of age, sex, and socioeconomic status (SES) on knee and hip revision rates in this population. We used data on admissions to all acute care hospitals in British Columbia (BC), Canada (population of four million people) from 1986 until 2004 (eighteen years of follow-up). Primary knee and hip replacement surgery for OA and revision procedures were identified using diagnostic (ICD-9, ICD-10) codes and surgical procedure codes. We excluded cases admitted due to injury or neoplasm. SES was assigned based on residential address linked to census data at the level of enumeration area (ecological variable), and analyzed according to quintiles or deciles of the distribution. In the analysis, we used Kaplan-Meier survival curves to describe the risk of first revision following first primary replacement surgery over time and parametric (Weibull) survival regression models to analyze the effects of joint (hip vs. knee) age, sex, and SES on revision rates. Death, emigration, and another primary joint replacement were treated as censoring events. Between 1986 and 2004, we observed 24,169 first primary hip replacements and 22,875 first primary knee replacements. In these patients, there were 1,313 hip revisions and 914 knee revisions following a primary replacement. The risk of revision at five, ten and fifteen years after primary replacement according to joint and sex were identified The overall risks were 10.1% for the hip and 8.7% for the knee at ten years, and 15.5% and 14.7%, respectively, at fifteen years. Risk of revision (%) following first primary joint replacement surgery Hip Knee Years Men Women Men Women 5 5.0 3.9 4.6 3.8 10 11.0 9.4 9.7 8.0 15 17.8 14.1 18.5 12.4 In a multivariate survival regression model including joint, age, sex, and SES, only age and sex were significantly associated with revisions. The hazard ratio was 1.2 for men compared with women (p< 0.0001). Revision rates were higher in younger persons, with hazard ratios increasing from 1.7 for age 70–79 (p< 0.0001) to 3.9 for age < 49 (p< 0.0001) compared with age 80+. After adjusting for age and sex, SES was not significantly associated with revision risk following primary hip or knee replacement surgery in this population (p=0.75). This is one of the largest and longest cohort studies in North America to look at the epidemiology of revision procedures following hip and knee replacement for OA. Higher rates in men and in younger persons are consistent with previous reports. The lack of association between revision risk and SES in BC is an important finding given current concerns about socioeconomic disparities in access to and outcomes of treatment for OA

Introduction. Reducing readmissions after total joint arthroplasty (TJA) is challenging. Pre-operative risk stratification and optimization pre surgical care may be helpful in reducing readmission rates after primary TJA. Assessment of the predictive value of individual modifiable risk factors without a tool to properly stratify patients may not be helpful to the surgical community to reduce the risk of readmission. We developed a scoring system: Readmission Risk Assessment Tool (RRAT) as part of a Perioperative Orthopaedic Surgical Home model that allows for risk stratification in patients undergoing elective primary TJA at our institution. We analyzed the relationship between the RRAT score and readmission following primary hip or knee arthroplasty. Methods. The RRAT, which is scored incrementally based on the number and severity of modifiable comorbidities was used to generate readmission scores for a cohort of 207 readmitted and 2 cohorts of 234 (random and age-matched) non-readmitted patients each. Regression analysis was performed to assess the strength of association between individual risk factors, RRAT score and readmissions. We also calculated the odds and odds ratio (OR) at each level of RRAT score to identify patients with relatively higher risk of readmission. Results. There were 207(2.08%) 30-day readmissions in 9,930 patients over a 6-year period (2008 to 2013). Surgical site infection was the most common cause of readmission (93 cases, 45%). The median RRAT scores were 3 (IQR: 1, 4) and 1 (IQR: 0, 2) for readmitted group and non-readmitted group respectively. The RRAT score was significantly associated with readmission with odds ratio between 1.5 and 1.9 under various model assumptions. A RRAT score of 3 or higher resulted in higher odds of readmission. Discussion and Conclusion. Population health management, cost-effective care and optimization of outcomes to maximize value are the new maxims for healthcare delivery in the United States. The RRAT has a significant association with readmission following joint arthroplasty and could potentially be a clinically meaningfully tool for risk mitigation

Aims

The COVID-19 pandemic led to a national suspension of “non-urgent” elective hip and knee arthroplasty. The study aims to measure the effect of the COVID-19 pandemic on total hip arthroplasty (THA) and total knee arthroplasty (TKA) volume in Scotland. Secondary objectives are to measure the success of restarting elective services and model the time required to bridge the gap left by the first period of suspension.