Abstract

Aims. In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods. This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results. The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion. Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies. Cite this article: Bone Jt Open 2023;4(10):791–800

Aims. The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness. Methods. A total of 316 patients were recruited and randomly assigned to either surgical reconstruction or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment). Healthcare resource use and health-related quality of life data (EuroQol five-dimension five-level health questionnaire) were collected in the trial at six, 12, and 18 months using self-reported questionnaires and medical records. Using intention-to-treat analysis, differences in costs, and quality-adjusted life years (QALYs) between treatment arms were estimated adjusting for baseline differences and following multiple imputation of missing data. The incremental cost-effectiveness ratio (ICER) was estimated as the difference in costs divided by the difference in QALYs between reconstruction and rehabilitation. Results. At 18 months, patients in the surgical reconstruction arm reported higher QALYs (0.052 (95% confidence interval (CI) -0.012 to 0.117); p = 0.177) and higher NHS costs (£1,017 (95% CI 557 to 1,476); p < 0.001) compared to rehabilitation. This resulted in an ICER of £19,346 per QALY with the probability of surgical reconstruction being cost-effective of 51% and 72% at a willingness-to-pay threshold of £20,000 and £30,000 per QALY, respectively. Conclusion. Surgical reconstruction as a management strategy for patients with long-standing ACL injury is more effective, but more expensive, at 18 months compared to rehabilitation management. In the UK setting, surgical reconstruction is cost-effective. Cite this article: Bone Joint J 2024;106-B(1):38–45

Abstract. Introduction. Approximately 15–20% of patients report chronic pain three months after total knee replacement (TKR). The STAR care pathway is a clinically important and cost-effective personalised intervention for patients with pain 3 months after TKR. The pathway comprises screening, assesment, onward referral for treatment and follow-up over one year. In a multicentre randomised controlled trial comparing the pathway with usual care, the pathway improved pain at 6 and 12 months. This study examined the longer-term clinical and cost-effectiveness of the STAR care pathway. Methodology. STAR trial participants were followed-up at a median of 4 years post-randomisation. Co-primary outcomes were self-reported pain severity and interference in the replaced knee, assessed with the Brief Pain Inventory (BPI). Resource use from electronic hospital records was valued with UK reference costs. Results. Of the 337 participants active at trial completion, 326 had confirmed vital status, and 226 (69%) provided outcome data at a median of 4 years. The between-group difference in mean BPI severity score was −0.42 (95% CI −1.07, 0.23; p=0.20) and for BPI interference was −0.64 (95% CI −1.41, 0.12; p=0.10), favouring the intervention. Multiple imputation analyses led to attenuations of about 0.2 points. Mean hospital admission costs over four years were £2461.49 (95% CI £1354.42, £3568.57) in the intervention arm and £3791.68 (95% CI £2095.12, to £5488.24) in usual care. Conclusion. These data are consistent with sustained benefits from the STAR care pathway at 4 years, albeit attenuated and with wider confidence intervals, in part attributable to attrition after 1 year

Introduction. Previous studies on Medicare populations have shown improved outcomes and decreased 90-day episode-of-care costs with robotic assisted total knee arthroplasty (rTKA). The purpose of this study was to evaluate the expenditures and utilization following rTKA in the under 65 y/o population. Methods. TKA procedures were identified using the OptumInsights Inc. database. A two-year window was studied. The procedures were stratified in two groups: the rTKA or manual (mTKA) cohorts. Propensity score matching (PSM) was performed at 1:5. Utilization and associated costs were analyzed for 90 days following the index procedure. 357 rTKA and 1785 mTKA were included in this analysis. Results. Within the 90 days following the surgery, patients who had robotic assisted procedures were less likely to utilize inpatient services (2.24 vs. 4.37%; p=0.0444) and skilled nursing visits (SNF) (1.68 vs. 6.05%; p<0.0001). No patients in the robotic TKA group went to inpatient rehab while 0.90% of the manual cases went to an inpatient rehabilitation facility. Patients who utilized a home health aide in the rTKA arm utilized significantly fewer days of home health (5.33 vs. 6.36 days; p=0.0037). Cost associated with the utilization of these services was lower in the rTKA arm; the overall post-surgery expenditures were $1,332 less in the rTKA arm ($6,857 vs. $8,189; p=0.0018). The 90-day global expenditures (index plus post-surgery) were $4,049 less in the rTKA arm ($28,204 vs. $32,253; p<0.0001). Lastly, length of stay (LOS) after surgery was nearly a day less for the rTKA arm (1.80 vs. 2.72 days; p<0.0001). Conclusion. Robotic assisted TKA was associated with shorter LOS, reduced utilization of services and reduced 90-day payer costs when compared to the manual TKA. For figures, tables, or references, please contact authors directly

Abstract. Introduction. This multi-centre randomised controlled trial evaluated the clinical and cost effectiveness of liposomal bupivacaine for pain and recovery following knee replacement. Methodology. 533patients undergoing primary knee replacement were randomised to receive either liposomal bupivacaine (266mg) plus bupivacaine hydrochloride (100mg) or control (bupivacaine hydrochloride 100mg), administered at the surgical site. The co-primary outcomes were pain visual analogue score (VAS) area under the curve (AUC) 6 to 72hours and the Quality of Recovery 40 (QoR-40) score at 72hours. Results. Primary analysis found no difference in pain VAS AUC 6 to 72hours between liposomal bupivacaine and control (MD -21.5 (97.5% CI -46.8 to 3.8; p=0.057)), nor the QoR-40 at 72hours (MD 0.54, 97.5% CI -2.05 to 3.13, p=0.643). Analyses of pain VAS and QoR-40 scores on days 0, 1, 2 and 3 demonstrated only one significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (day0; MD -0.54, 97.5% CI -1.07 to -0.02; p=0.021). No difference in cumulative opioid consumption or functional outcome at 6weeks, 6months or 1year was detected. Heath economic analysis found liposomal bupivacaine to be less effective in terms of QALYs as well as more costly. No difference in adverse events between arms was identified. Conclusion. This is the largest RCT evaluating the clinical and cost effectiveness of liposomal bupivacaine It found that compared to bupivacaine hydrochloride local infiltration of liposomal bupivacaine at the surgical site does not provide any clinical or cost benefit for knee replacement and therefore should not be routinely used

Abstract. Design. A pragmatic, multicentre, parallel-group, randomised controlled trial to determine whether the intervention is superior to comparator. Setting. 20 NHS Hospitals. Population. NHS patients <60 years with moderate-severe symptomatic knee OA localised to the medial compartment in whom surgical intervention is indicated. Intervention. Surgery with medial opening wedge high tibial osteotomy (HTO) followed by standard postoperative rehabilitation based on local pathways. Comparator. Tailored non-surgical intervention delivered within an NHS physiotherapy department delivered over 6-contact sessions within a period of 4 months. Outcomes. Primary outcome - 24-month Knee Injury and Osteoarthritis Outcome Score (KOOS); Secondary outcomes - OKS, FJS-12, EQ-5D-3L, Pittsburgh Sleep Problem Scale, Return to Work, secondary surgical interventions and complications at 12 and 24 months following randomisation. Health economic evaluation - 24-month within trial analysis, and a decision analytic simulation model to account for the impacts of future knee replacements (and associated revisions), and their timing relative to retirement and employment potential. Process evaluation – to explore trial eligibility, recruitment and retention rates, acceptability of intervention implementation and patient experience of taking part/contextual factors that influence this. Follow up. 12 months and 24 months post-randomisation. Sample size. 224 patients; (90% power, 2-sided p=0.05, equivalent to a sample size of 97 per group). Allowing for 15% loss to follow up, 112 patients will be recruited to each arm of the trial. Project timelines. Start date 1 August 2022, total project duration 60 months including a 9-month, 5-site internal pilot, with a recruitment rate of 0.7 patients/site/month

Abstract. Patellofemoral Arthroplasty (PFA) is an alternative to TKA for patellofemoral osteoarthritis that preserves tibiofemoral compartments. It is unknown how implant positioning affects biomechanics, especially regarding the patella. This study analysed biomechanical effects of femoral and patellar component position, hypothesising femoral positioning is more important. Nine cadaveric knees were studied using a repeated-measures protocol. Knees were tested intact, then after PFA implanted in various positions: neutral (as-planned), patellar over/understuffing (±2mm), patellar tilt, patellar flexion, femoral rotation, and femoral tilt (all ±6°). Arthroplasties were implemented with CT-designed patient-specific instrumentation. Anterior femoral cuts referenced Whiteside's line and all femoral positions ensured smooth condyle-to-component transition. Knee extension moments, medial patellofemoral ligament (MPFL) length-change, and tibiofemoral and patellofemoral kinematics were measured under physiological muscle loading. Data were analysed with one-dimensional statistical parametric mapping (Bonferroni-Holm corrected). PFA changed knee function, altering extension moments (p<0.001) and patellofemoral kinematics (p<0.05), but not tibiofemoral kinematics. Patellar component positioning affected patellofemoral kinematics: over/understuffing influenced patellar anterior translation and the patellar tendon moment arm (p<0.001). Medially tilted patellar cuts produced lateral patellar tilt (p<0.001) and vice versa. A similar inverse effect occurred with extended/flexed patellar cuts, causing patellar flexion and extension (p<0.001), respectively. Of all variants, only extending the patellar cut produced near-native extension moments throughout. Conversely, the only femoral effect was MPFL length change between medially/laterally rotated components. PFA can restore native knee biomechanics. Provided anterior femoral cuts are controlled and smooth condyle-to-component transition assured, patellar position affects biomechanics more than femoral, contradicting the hypothesis

Aims

Surgeon and patient reluctance to participate are potential significant barriers to conducting placebo-controlled trials of orthopaedic surgery. Understanding the preferences of orthopaedic surgeons and patients regarding the design of randomized placebo-controlled trials (RCT-Ps) of knee procedures can help to identify what RCT-P features will lead to the greatest participation. This information could inform future trial designs and feasibility assessments.

Introduction. Opioid abuse is a national epidemic. Traditional pain management after total knee arthroplasty (TKA) relied heavily on opioids. The evidence that in-hospital multimodal pain management (MMPM) is more effective than opioid-only analgesia is overwhelming. There has been little focus on post-discharge pain management. The purpose of this study was to determine whether MMPM after TKA could reduce opioid consumption in the 30-day period after hospital discharge. Methods. This was a prospective, two-arm, comparative study with a provider cross-over design. The first arm utilized a standard opioid-only (OO) prn regimen. The second arm utilized a 30-day MMPM regimen (standing doses of acetaminophen, metaxalone, meloxicam, gabapentin) and opioid medications prn. Surgeons crossed over protocols every four weeks. The primary outcome measure was VAS pain score. Secondary outcome measures included morphine milligram equivalents (MME) consumed, failure of the protocol, and manipulation under anesthesia (MUA). A pre-hoc power analysis was performed for the primary outcome measure and an intent-to-treat analysis was done utilizing a longitudinal mixed model. Results. There were 43 patients in the OO cohort and 39 patients in the MMPM cohort. There was no difference in the baseline demographics or preoperative scores (p=0.94). There was no clinically meaningful difference in VAS score between the two groups at any time. The average opioid consumption at 30-days was 469 and 344 MME's for the OO and MMPM cohorts, respectively (p=0.026). 19/43 (44.2%) patients in the OO cohort failed vs. 4/39 (10.3%) in the MMPM cohort (p=0.002). There was 1 MUA in the OO and none in the MMPM cohort (p=0.338). Discussion. A 30-day post-discharge multimodal pain regimen reduced opioid use after TKA. Opioid-only regimens are at an increased risk of failure to control pain. As a result of this study, multimodal pain management after hospital discharge is standard at our institution

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The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.

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While residual fixed flexion deformity (FFD) in unicompartmental knee arthroplasty (UKA) has been associated with worse functional outcomes, limited evidence exists regarding FFD changes. The objective of this study was to quantify FFD changes in patients with medial unicompartmental knee arthritis undergoing UKA, and investigate any correlation with clinical outcomes.

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Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

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Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR).

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Unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) have both been shown to be effective treatments for osteoarthritis (OA) of the knee. Many studies have compared the outcomes of the two treatments, but less so with the use of robotics, or individualized TKA alignment techniques. Functional alignment (FA) is a novel technique for performing a TKA and shares many principles with UKA. Our aim was to compare outcomes from a case-matched series of robotic-assisted UKAs and robotic-assisted TKAs performed using FA.

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The aim of this study was to determine whether obesity had a detrimental effect on the long-term performance and survival of medial unicompartmental knee arthroplasties (UKAs).

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The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

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The primary objective of this study was to compare the five-year tibial component migration and wear between highly crosslinked polyethylene (HXLPE) inserts and conventional polyethylene (PE) inserts of the uncemented Triathlon fixed insert cruciate-retaining total knee arthroplasty (TKA). Secondary objectives included clinical outcomes and patient-reported outcome measures (PROMs).

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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.

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To assess the incidence of radiological lateral osteoarthritis (OA) at 15 years after medial unicompartmental knee arthroplasty (UKA) and assess the relationship of lateral OA with symptoms and patient characteristics.