Aims. Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice. Methods. This retrospective cohort study included consecutive patients undergoing TKA at a specialist centre in the UK between November 2010 and December 2012. Data were collected using a bespoke electronic database and cross-referenced with national arthroplasty audit data, with variables including: preoperative characteristics, intraoperative factors, complications, and mortality status. Patient-reported outcome measures (PROMs) were collected by a specialist research team at ten years post-surgery. There were 536 TKAs, of which 308/536 (57.5%) were in female patients. The mean age was 69.0 years (95% CI 45.0 to 88.0), the mean BMI was 32.2 kg/m. 2. (95% CI 18.9 to 50.2), and 387/536 (72.2%) survived to ten years. There were four revisions (0.7%): two deep infections (requiring debridement and implant retention), one aseptic loosening, and one haemosiderosis. Results. Kaplan-Meier analysis demonstrated no difference in implant survival according to sex, age, or obesity status. Ten-year PROMs were available for 196/387 (50.6%) surviving patients and were excellent: mean Oxford Knee Score 34.4 (95% CI 32.7 to 36.1); mean Forgotten Joint Score (FJS) 51.2 (95% CI 16.1 to 86.3); mean EuroQol five-dimension five-level questionnaire score 69.9 (95% CI 46.8 to 93.0); 141/196 (71.9%) achieved the 22-point FJS patient-acceptable symptom state (PASS); and 156/196 (79.6%) were “very satisfied or satisfied”. Conclusion. This is the only large study reporting ten-year implant survival and functional outcomes of TKA using a cemented single-radius design and with a CS tibial bearing construct. The findings of excellent implant survival, safety, and functional outcomes indicate that this combination is a safe and effective option in routine TKA. Further investigation of this single-radius design TKA with CS tibial bearings with well-matched patient study groups will allow further insight into the performance of these implants. Cite this article: Bone Joint J 2024;106-B(8):808–816

Abstract. Multidisciplinary team (MDT) meetings in orthopaedic surgery are evolving. The goals include patient optimisation, surgical planning and discharge arrangements, individually on a patient specific basis. In line with British Association Surgery of the Knee and GIRFT guidelines, we report our regional experience on the implementation and evolution of our regional Revision Knee Arthroplasty MDT. We undertook a retrospective review of the process, cases discussed and quality assurance conducted in the weekly MDT. Since implementation of the MDT meeting in January 2019, 550 patients with painful joint replacements have been discussed. In May 2021, we formalised our ‘terms of reference’ and ‘standard operating procedures’ which are adhered to by the consultants operating within the network, all of whom attend the meeting. A proforma has been developed and is completed for all cases capturing all pertinent information. All cases are graded according to R1, R2, or R3 complexity scale. Since its inception, the MDT has looked at all post-operative imaging, we now describe a new classification system for grading the appearances. Confirmation of the pre-operative plan and actual surgical intervention is reviewed and audited. In addition, confirmation of indication of revision at the time of operation is reviewed and validated for accuracy with benefits to the unit, individual surgeon and the NJR. In conclusion, the implementation of the revision MDT facilitating pre-operative revision arthroplasty discussion and post-operative quality assurance processes enable surgeons to educate, reflect on their practice and ensure that the highest standards of care are being provided

Abstract. Introduction. The Wells score is commonly used to assess the risk of proximal Deep Vein Thrombosis (DVT) following Knee Arthroplasty (KA). The National Institute for Health and Care Excellence (NICE) guidelines recommend an Ultrasound scan in patients with a Wells score of 2 points or more. We wanted to assess how often this protocol resulted in a scan being done and how many were negative. Methodology. Details of all postoperative Ultrasound scans performed up to 90 days were audited in a high-volume unit between 1st January 2016 and 31st December 2020. This included all Lower Limb Arthroplasty patients. Results. Out of a total of 4955 KA (4506 Total Knee Arthroplasty, 449 Unilateral Knee Arthroplasty), 449 (9.1%) had a total of 561 scans, with 17 (3.0%) scans demonstrating a proximal DVT. Thus 97.0% of Ultrasound scans were negative. Conclusion. The present NICE guidelines with the two-Level DVT Wells score are inappropriate for the management of suspected proximal DVT following KA. We propose that swelling that fails to reduce after 4 hours of elevation, or new swelling after a period of recumbent rest, would be more appropriate indications for a scan and negative scans should not be repeated without a change in symptoms. Unless there are pressing clinical indications, therapeutic anticoagulation should not commence in the absence of a diagnosis

Aims. The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). Methods. This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant. Results. From 1998 to 2019, 8,301 patients (8,894 knees) underwent RTKA surgery in Scotland (median age at RTKA 70 years (interquartile range (IQR) 63 to 76); median follow-up 6.2 years (IQR 3.0 to 10.2). In all, 4,764 (53.6%) were female, and 781 (8.8%) were treated for infection. Of these 8,894 knees, 957 (10.8%) underwent a second revision procedure. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95% CI 86.5 to 88.1). Adjusting for sex, age, surgeon volume, and indication for revision, high hospital case volume was significantly associated with lower risk of re-revision (HR 0.78 (95% CI 0.64 to 0.94, p < 0.001)). The risk of re-revision steadily declined in centres performing > 20 cases per year; risk reduction was 16% with > 20 cases; 22% with > 30 cases; and 28% with > 40 cases. The lowest level of risk was associated with the highest volume centres. Conclusion. The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA. Cite this article: Bone Joint J 2021;103-B(4):602–609

Introduction. In November 2017, the Center for Medicare and Medicaid Services (CMS) finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) procedures from the Medicare inpatient-only (IPO) list of procedures. This action had significant and unexpected consequences. For several years, CMS has utilized a rule called the “Two-Midnight Rule” to define outpatient status for all procedures not on the IPO list. CMS made TKA subject to the “Two-Midnight Rule” in conjunction with the decision to move TKA off the IPO list. According to the “Two-Midnight Rule,” a hospital admission should be expected to span at least two midnights in order to be covered as an inpatient procedure. If it can be reliably expected that the patient will not require at least two midnights in the hospital, the “Two-Midnight Rule” suggests that the patient is considered an outpatient and is therefore subject to outpatient payment policies. Under prior guidance related to the “Two-Midnight Rule;” however, CMS also states that Medicare may treat some admissions spanning less than two midnights as inpatient procedures if the patient record contains documentation of medical need. The final rule was clear in stating CMS's expectation was that the great majority of TKAs would continue to be provided in an inpatient setting. Methods. We looked at 3 different levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of fee for service (FFS) inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April of 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in inpatient classification of TKA patients over time, number of Quality Improvement Organization (QIO) audits, compliance solutions of organizations for the new rule and cost implications of those compliance solutions were evaluated. Results. Hospital reimbursement averages $10,122 in an outpatient facility (includes implant, other supplies, ancillary staff, etc.) but does NOT include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in reimbursement to hospitals varies widely however due to nuances in the CMS reimbursement formula (90. th. percentile decrease, $6,725 vs 10th percentile $2,048). Physician payments are the same in both settings (avg $1,403). TKA patients not designated for in-patient admissions are not eligible for bundle payment programs thus removing the healthiest, most predictable patients from the program. Patients designated as outpatients are subject to higher out of pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. A survey of AAHKS surgeons demonstrated that 44.74% were doing inpatient designation only, 17.89% were doing outpatient designation only, 25.53 % designated patients as necessary, and 10% were designated by the hospital. This survey showed that 66/374 (17.65%) of AAHKS responders had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of a large academic medical center demonstrated that since January 1, 2018, 470/690 (68.1%) of CMS TKA patients left the institution in less than 2 midnights. During this time period the institution was subjected to 2 QIO audits. All CMS patients had been designated as inpatients prior to May 2019. Conclusions. There are many unintended consequences to the IPO rule application to TKA. Clearly, more study is needed to provide better guidelines to knee replacement surgeons. A well-defined outpatient TKA bundle would allow CMS and TKA surgeons to better serve their patients. For figures, tables, or references, please contact authors directly

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The aim of this study was to assess factors associated with the estimated lifetime risk of revision surgery after primary knee arthroplasty (KA).

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The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis.

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The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness.

At our tertiary, large, academic healthcare system, we have access to an academic medical center (AMC), a community based, orthopedic friendly, efficient hospital (CBH) and several ambulatory care centers (ASC) which are being prepared to provide same day discharge (SDD) TJA and UKA. We had a near-capacity AMC with an excellent ability to care for medically and technically complicated TJA patients. However, efficiency was less than desired regardless of case complexity with an average effective case time of 4 hours. Concurrently, the orthopaedically, under-utilized community-based hospital (CBH) wanted to increase volume, improve margins, and become a TJA Center of Excellence with the ability to provide an efficient Hospital Outpatient Department (HOPD) and SDD TJA surgery experience. Methods. The CBH had a main operating floor and a separate floor of four OR suites which were repurposed with the goal of utilizing these rooms for TJA four days per week with an average of 3.5 cases per room per day. We preferentially performed primary, uncomplicated TJA, UKA, and minimally invasive TJA at the CBH. Revision surgeries, patients with extensive medical comorbidities, and complex primary surgeries would be performed at the AMC. Our goals were to decrease costs, readmissions, length of stay, and increase margins at the CBH while increasing efficiency, revenue and volume. Protocols were developed to facilitate SDD UKA and THA at both hospitals as well as rapid recovery protocols for TKA at both hospitals with the understanding that the CBH would perform more of these cases but the efficiency could also be implemented at the AMC when possible. We also needed a strategy to deal with TKA and eventually THA being removed from the Inpatient Only (IPO) list. CMS has utilized the “Two-Midnight Rule” to define outpatient status for both THA and TKA. This has distinct financial implications for the facility's reimbursement with outpatient being $10,123 on average versus $12,380 for inpatient status. A protocol-based system was put in place to make both hospitals compliant with the removal of TKA from the IPO List in order to avoid Quality Improvement Organization (QIO) and Recovery Audit Contractor (RAC) after implementation. Results. Comparing FY 2018 to FY 2019, volume increased 26.4% at the CBH. Outpatient case volume rose substantially from 14 cases to 243. Volumes were slightly decreased at the AMC (−4.57%) resulting in a substantial increase in margin contribution for the parent enterprise. Quality metrics at the CBH (surgical site infections (SSI), length of stay (LOS), readmissions, and mortality) were improved. LOS improved from 52% to 71% discharge before 48 hours. The LOS decreased 12% for THA and 8.1% for TKA. CBH readmission rates decreased from 1.38% to 0.9% with no deaths. Surgeon satisfaction is greatly improved as their volume, efficiency, quality metrics, and finances were enhanced. Financial performance was improved in aggregate and per case for the CBH. Although the CBH per-case revenue was 80.3% and 74.4% of the AMC for THA and TKA: the net margins were 3.6% and 18.8% higher for THA and TKA, respectively. The increased efficiency, lower hospital cost and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. Conclusions. A shifting reimbursement landscape, value-based payment initiatives, and increasing volume have challenged traditional TJA delivery systems. This demonstrates one strategy to help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient settings including ambulatory surgery centers which will be subjected to even further decreases in net revenue per patient

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Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear.

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To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

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This prospective study reports longitudinal, within-patient, patient-reported outcome measures (PROMs) over a 15-year period following cemented single radius total knee arthroplasty (TKA). Secondary aims included reporting PROMs trajectory, 15-year implant survival, and patient attrition from follow-up.

Introduction. Patient satisfaction is an important outcome measure after total knee arthroplasty (TKA) and is the ultimate goal of surgery. However, patient satisfaction reflects a complex construct of the patient's personal expectations and preferences in addition to subjective evaluation of outcome after TKA. Multiple studies have found a patient dissatisfaction rate of approximately 20% at 1 year after TKA. The purpose of this study is to determine whether there is an association between a single-item validated TKA satisfaction score and patient-reported outcome measures (PROMs) at 3 time points (1, 2, and 5 years after TKA) and to determine if dissatisfaction rate after TKA varies over time. Methods. A multi-center, prospective cohort of 12,952 patients (8,078 patients were assessed at 1-year, 702 patients at 2-year, and 4,172 patients at 5-year) undergoing primary TKA were enrolled by 230 surgeons in 28 states between 2012–2015. Surgeons practices varied in size, reimbursement models, and geographic setting ensuring that the cohort included diverse patient populations and delivery models. Surgeons agreed to invite all TKA patients to participate and sporadic audits of surgical logs validated that all patients were invited and > 90% of patients were included. Demographic and clinical data [age, gender, body mass index (BMI), and modified Charlson co-morbidity index (CCI)] were collected. Patient-reported outcome measures (PROMs) were collected pre-op and post-op at 1, 2, and 5 years using an internet-based platform including the KOOS (total score, and pain, ADL, QoL sub scores), KOOS Jr, SF-36 (PCS and MCS). We used the single-item satisfaction scale which was tested and validated by the Swedish Knee Arthroplasty Registry. The patients' responses were made on 5-point Likert scale (very satisfied, somewhat satisfied, neutral, somewhat dissatisfied, very dissatisfied). Patients were classified into 2 categories: satisfied group for patients who answered satisfied or very satisfied and dissatisfied group for patients answered neutral, somewhat dissatisfied, or very dissatisfied. Univariate analysis of the difference between the satisfied and dissatisfied patients' groups was performed using Mann-Whitney U test for continuous variables and chi-square test for categorical variables. Logistic regression model was performed to study the correlation between the satisfaction and PROMs with 95% confidence interval. Results. Mean age was 66.6 years, 62.7% were female, and mean BMI was 31.6. The CCI was 0 in 55.1%, 1 in 22%, 2–5 in 12.6% and ≥ 6 in 10.3%. Cumulative revision rate was 1.29% at 2 years. The 30-day adverse events incidence was 2.5% while the 90-day adverse events incidence was 4.7%. The dissatisfaction rate was 18.1% at 1-year, 11.5% at 2-year, and 8.5% at 5-year (P<0.001, Chi-square). Dissatisfaction significantly affects younger patients (<55 years) (P=0.04, Chi-square) and patients with high Charlson comorbidity index >1 (P=0.001, Chi-square). Low post-operative KOOS Pain, KOOS ADL, KOOS total score, KOOS JR, SF-36 PCS, and SP-36 MCS scores were significantly associated with dissatisfaction (P<0.001). At 5 years follow-up, in patients with KOOS scores greater than 70, 1.3% of patients were dissatisfied; with KOOS 50–70, 16.3% were dissatisfied and when KOOS < 50, 62.2% are dissatisfied. Logistic regression showed significant correlation of satisfaction with postoperative KOOS pain, KOOS ADL, KOOS QoL, KOOS total score, KOOS JR, and SF-36 PCS (P< 0.001) at 1-year, 2-year, and at 5-year. The MCS was correlated with patient satisfaction only at 1-year (P< 0.001). Conclusion. The patient dissatisfaction rate 5 years after TKA is 8.1% in FORCE-TJR patients which is significantly lower than 18.1% at 1-year. Less improvement of PROM scores after TKA are significantly associated with patient dissatisfaction. Postoperative PROM scores are associated with patient satisfaction at 1-year, 2-years, and 5-years. When the 5-year post- op KOOS total score is >70, 98.7% of patients are satisfied and only 1.3% are dissatisfied. Patient satisfaction is an important outcome measure after TKA that can be determined by asking a single question. However, in order to understand why a patient is dissatisfied, KOOS scores (KOOS pain, KOOS ADL, KOOS QoL) that assess specific postoperative outcomes can assist in determining the reason for patient dissatisfaction after TKA

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In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

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To identify the responsiveness, minimal clinically important difference (MCID), minimal clinical important change (MIC), and patient-acceptable symptom state (PASS) thresholds in the 36-item Short Form Health Survey questionnaire (SF-36) (v2) for each of the eight dimensions and the total score following total knee arthroplasty (TKA).

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Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component.

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The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA).

We assessed the outcome of patients who were lost to follow-up after arthroplasty by a single surgeon. The aim was to validate the surgeon’s data set with the Australian Orthopaedic Association National Joint Replacement Registry and determine the outcome of those patients lost to follow-up. Prospective data on patient demographics, operative details and outcomes of the surgeon’s 1192 primary unicompartmental knee arthroplasty (UKA) procedures were analysed. There were 69 knees in patients who were lost to follow-up, among whom the Registry identified 31 deaths and eight revisions. The cumulative percentage revision (CPR) at seven years using the additional Registry data was 8.8% (95% confidence interval (CI) 7 to 11). Using the surgeon’s data, the CPR at seven years was 8% (95% CI 6.3 to 10.1) for the best-case scenario where loss to follow-up was excluded, and 16% (95% CI 13.8 to 19.4) for the worst-case scenario, where all patients lost to follow-up were deemed to have been revised. There was a significantly higher mortality rate in those patients lost to follow-up. This study demonstrates that a national joint registry can be used by individual surgeons to establish more accurate revision rates in their arthroplasty patients. This is expected to facilitate a more rigorous audit of surgical outcomes by surgeons and lead to more accurate and uniform reporting of the results of arthroplasty in general

Our aim in this audit was to determine whether intensive rehabilitation post-operatively influenced length of stay and readmission rates for patients undergoing primary total knee arthroplasty. In September 2007, a dedicated weekend physiotherapy service was set up in our Trust for patients following joint arthroplasty at a cost of £30,000 per annum. A prospective audit was conducted over two six-month periods, before and after the introduction of this service, including 202 and 240 patients respectively. Patient demographics including ASA grade and strict inclusion and exclusion criteria were used. The effect of anaesthetic type on post-operative pain control was also reviewed. Chi-squared and Mann-Whitney tests were used to analyse non-parametric data. In the second cohort, with intensive rehabilitation, a statistically significantly higher number of patients were discharged within seven days of admission (64% vs 36%, p<0.01). This was despite there being a significantly higher number of patients with high ASA grades 3-4 in this cohort (37% vs 27%, p<0.05). The median length of stay in the second cohort was seven days compared to eight in the first cohort. There was a slight increase in rate of readmission within the second cohort but this was not statistically significant. We found that the addition of a femoral nerve block significantly reduced post-operative pain. We concluded that an annual financial saving to the Trust of approximately £118,000 could be made by the addition of an additional dedicated physiotherapist in our unit. Patients can be safely discharged sooner with intensive rehabilitation and may benefit in the longer term by improved knee function

Purpose of the study. To determine the effectiveness, complications and side effects of Rivaroxaban when used for extended thromboprophylaxis in patients undergoing primary and revision knee arthroplasty. Methods. Venous Thromboembolism (VTE) prophylaxis following knee arthroplasty remains controversial. As an Orthopaedic Unit, in July 2009 we developed guidelines to help ensure that our patient management was fully compliant with National Institute for Health and Clinical Excellence (NICE) guidelines regarding risk assessment and extended oral prophylaxis following primary and revision knee arthroplasty. We opted to trial the oral anticoagulant drug Rivaroxaban for an initial period of 12 months. All patients undergoing primary or revision knee arthroplasty between 1. st. July 2009 and 30. th. June 2010 and who had no contraindications to the prescription of Rivaroxaban were included in a prospective audit aimed at determining compliance with the newly developed unit guidelines as well as the effectiveness and possible side effects/complications associated with the drug therapy. All patients were monitored for a period of 90 days post operatively. Results. A total of 415 patients were included in the audit (336 primary knee arthroplasty, 27 revision knee arthroplasty, 6 patello-femoral resurfacing, 46 medial unicompartmental knee arthroplasty). Of this group eight had a confirmed VTE (six deep vein thrombosis, two pulmonary embolism). A further 29 patients had post-operative complications which may be attributed in part to the action of Rivaroxaban. The drug was discontinued prematurely for 22 patients. Conclusions. Our results indicate that Rivaroxaban is effective in providing extended VTE prophylaxis to patients undergoing knee arthroplasty surgery. However, as anticipated, anticoagulation therapy does cause associated wound problems