Primary hip and knee joint replacements in Canada have been estimated to cost over $1.4 billion dollars annually, with revision surgery costing $177 million. The most common cause of revision arthroplasty surgery in Canada is infection. Periprosthetic joint infections (PJIs) are a devastating though preventable complication following arthroplasty. Though variably used, antibiotic laden bone cement (ALBC) has been demonstrated to decrease PJIs following primary total knee arthroplasty (TKA). Unfortunately, ALBC is costlier than regular bone cement (RBC). Therefore, the aim of this study was to determine if the routine use of ALBC in primary TKA surgery is a cost-effective practice from the perspective of the Canadian healthcare system.

A decision tree was constructed using a decision analysis software (TreeAge Software, Williamstown, Massachusetts) to a two-year time horizon comparing primary TKA with either ALBC or RBC from the perspective of a single-payer healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality adjusted life years (QALYs). Model inputs for cost were derived from regional and national databases. Health utilities and probability parameters were derived from the latest literature. One-way deterministic sensitivity analysis was performed on all model parameters. The primary outcome of this analysis was an incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $50,000 per QALY.

Primary TKA with ALBC (TKA-ALBC) was found to be more cost-effective compared to primary TKA with RBC (TKA-RBC). More specifically, TKA-ALBC dominated TKA-RBC as it was less costly on the long term ($11,160 vs. $11,118), while providing the same QALY (1.66). The ICER of this cost-utility analysis (CUA) was $-11,049.72 per QALY, much less than the WTP threshold of $50,000 per QALY. The model was sensitive to costs of ALBC-TKA as well as the probability of PJI following ALBC-TKA and RBC-TKA. ALBC ceased to be cost effective once the cost of ALBC was greater than $223.08 CAD per bag of cement.

The routine use of ALBC in primary TKA is a cost-effective practice in the context of the Canadian healthcare system as long as the cost of ALBC is maintained at a reasonable price and the published studies to-date keep supporting the efficacy of ALBC in decreasing PJI following primary TKA. Further, this analysis is very conservative, and ALBC is likely much more cost-effective than presented. This is due to this model's revision surgery cost parameter being based on the average cost of all revision TKA surgery in Canada, regardless of etiology. Considering many PJIs require two-stage revisions, the cost parameter used in this analysis for revision surgery is an underestimate of true cost. Ultimately, this is the first cost-effectiveness study evaluating this topic from the perspective of the Canadian healthcare system and can inform future national guidelines on the subject matter.

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.

The Accolade®TMZF is a taper-wedge cementless metaphyseal coated femoral stem widely utilized from 2002-2012. In recent years, there have been reports of early catastrophic failure of this implant. Establishing a deeper understanding of the rate and causes of revision in patients who developed aseptic failure in stems with documented concerns about high failure rates is critical. Understanding any potential patient or implant factors which are risk factors for failure is important to inform both clinicians and patients. We propose a study to establish the long-term survival of this stem and analyze patients who underwent aseptic revision to understand the causes and risk factors for failure.

A retrospective review was undertaken of all patients who received a primary total hip arthroplasty with an Accolade® TMZF stem at a high-volume arthroplasty center. The causes and timing of revision surgery were documented and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to minimize loss to follow-up. Survivorship analysis was performed with use of the Kaplan-Meier curves to determine the overall and aseptic survival rates at final follow-up. Patient and implant factors commonly associated with aseptic failure were extracted and Cox proportional hazards model was used.

A consecutive series of 2609 unilateral primary THA patients implanted with an Accolade®TMZF femoral hip stem were included. Mean time from primary surgery was 12.4 years (range 22 days to 19.5 years). Cumulative survival was 96.1% ± 0.2 at final follow-up. One hundred and seven patients underwent revision surgery with aseptic loosening of the femoral component was the most common cause of aseptic failure in this cohort (33/2609, 1.3%). Younger age and larger femoral head offset were independent risk factors for aseptic failure.

To our knowledge, this is the largest series representing the longest follow-up of this taper-wedge cementless femoral implant. Despite early concerns, the Accolade® TMZF stem has excellent survivorship in this cohort. Trunnionosis as a recognized cause for revision surgery was rare. Younger age and larger femoral head offset were independent risk factors for aseptic failure.

During total knee arthroplasty (TKA), a tourniquet is often used intraoperatively. There are proposed benefits of tourniquet use including shorter duration of surgery, improved surgical field visualization and increased cement penetration which may improve implant longevity. However, there are also cited side effects that include increased post-operative pain, slowed recovery, skin bruising, neurovascular injury and quadriceps weakness. Randomized controlled trials have demonstrated no differences in implant longevity, however they are limited by short follow-up and small sample sizes. The objective of the current study was to evaluate the rates of revision surgery among patients undergoing cemented TKA with or without an intraoperative tourniquet and to understand the causes and risk factors for failure.

A retrospective cohort study was undertaken of all patients who received a primary, cemented TKA at a high-volume arthroplasty centre from January 1999 to December 2010. Patients who underwent surgery without the use of a tourniquet and those who had a tourniquet inflated for the entirety of the case were included. The causes and timing of revision surgery were recorded and cross referenced with the Canadian Institute of Health Information Discharge Abstract Database to reduce the loss to follow-up. Survivorship analysis was performed with the use of Kaplan-Meier curves to determine overall survival rates at final follow-up. A Cox proportional hazards model was utilized to evaluate independent predictors of revision surgery.

Data from 3939 cases of primary cemented TKA were available for analysis. There were 2276 (58%) cases in which a tourniquet was used for the duration of the surgery and 1663 (42%) cases in which a tourniquet was not utilized. Mean time from the primary TKA was 14.7 years (range 0 days - 22.8 years) when censored by death or revision surgery. There were 150 recorded revisions in the entire cohort, with periprosthetic joint infection (n=50) and aseptic loosening (n=41) being the most common causes for revision. The cumulative survival at final follow-up for the tourniquetless group was 93.8% at final follow-up while the cumulative survival at final follow-up for the tourniquet group was 96.9% at final follow-up. Tourniquetless surgery was an independent predictor for all-cause revision with an HR of 1.53 (95% CI 1.1, 2.1, p=0.011). Younger age and male sex were also independent factors for all cause revision.

The results of the current study demonstrate higher all-cause revision rates with tourniquetless surgery in a large cohort of patients undergoing primary cemented TKA. The available literature consists of short-term trials and registry data, which have inherent limitations. Potential causes for increased revision rates in the tourniquetless group include reduced cement penetration, increased intraoperative blood loss and longer surgical. The results of the current study should be taken into consideration, alongside the known risks and benefits of tourniquet use, when considering intraoperative tourniquet use in cemented TKA.

Overall, hip and knee total joint replacement (TJR) patients experience marked benefit, with reported satisfaction rates of greater than 80% with regard to pain relief and improved function. However, many patients experience ‘nuisance’ symptoms, an annoyance which may cause discomfort, which can negatively impact postoperative satisfaction. The purpose of this study was to evaluate the prevalence of nuisance symptoms among TJR patients and impact on overall patient satisfaction.

A prospective survey study to assess type and prevalence of primary hip/knee TJR related nuisance symptoms, and impact on patient satisfaction at six-months to one-year post-TJR was conducted. The survey was administered over a one-year period at one academic arthroplasty centre. Survey questions tapped occurrence of commonly reported nuisance symptoms (e.g. localized pain, swelling, stability, incision appearance/numbness, stiffness, clicking/noise, ability to perform activities of daily living), and impact of the symptom on overall hip/knee satisfaction rated on a 10-point visual analogue scale (VAS), (0=no impact, 10=to a great extent). Overall VAS satisfaction with TJR was also assessed (0=not at all satisfied, 10=extremely satisfied). Survey responses were analysed using descriptive statistics.

The sample comprised of 974 primary TJR patients, including 590 knees (61%) and 384 hips 39%) who underwent surgery over a one-year period. Among knees, the most commonly reported nuisance symptoms and associated impact to satisfaction per mean VAS scores included: difficulty kneeling (78.2%, mean VAS 4.3, ±3.3), limited ability to run or jump (71.6%, VAS 3.3, ±3.3), numbness around incision (46.3%, VAS 3.8, ±3.3), clicking/noise from the knee (44.2%, VAS 2.7, ±2.7) and stiffness (43.3%, 3.3, ±2.7) following knee arthroplasty. Overall, 88.1% of knee patients surveyed experienced at least one self-reported nuisance symptom at one-year postoperative. Mean overall VAS satisfaction with knee TJR was reported as 9/10 (±1.7). Among hip TJR patients, the most commonly reported nuisance symptoms and associated impact to satisfaction per VAS scores were: limited ability to run or jump (68.6%, VAS 3.4, ±3.4), muscular pain in the thigh (44.8%, VAS 3 ±2.7), limp when walking (37.6%, VAS 4.1, ±3.2), hip stiffness (31%, VAS 3.1, ±2.4), and new or worsening low back pain (24.3%, VAS 2.9, ±2.5). Overall, 93.7% of patients experienced at least one self-reported nuisance symptom at one-year postoperative. Mean overall VAS satisfaction following total hip arthroplasty at one year was reported as 8.9/10 (±1.7).

Nuisance symptoms following primary total hip and knee arthroplasty are very common. Despite the high prevalence of such symptoms, impact of individual symptoms to overall TJR satisfaction is minimal and overall TJR patient satisfaction remains high. Careful preoperative counselling regarding the prevalence of such symptoms is prudent and will help establish realistic expectations following primary hip and knee TJR.

Prosthetic joint infections (PJI) are amongst the most feared postoperative complication of total joint replacement (TJR). PJIs are associated with significant morbidity ranging from functional impairment to amputation. Staphylococcus aureus (S. aureus) is one of the most common causative organisms involved in PJI. More than one quarter of the general population are S. aureus carriers, and carrier status has been shown to increase the risk of developing surgical site infections including PJIs. Decolonization of S. aureus carriers prior to surgery has demonstrated promising results in general surgery, however, solid evidence supporting decolonization in orthopaedic patients is lacking. We aimed to seek further evidence supporting pre-operative screening and S. aureus decolonization in patients undergoing primary or revision hip and knee TJR.

A quasi-experimental quality improvement study was conducted to compare the 5-year baseline rates of deep PJIs to a one-year screening and decolonization intervention period. All consecutive patients who underwent primary or revision TJR at one tertiary care hospital in Hamilton, ON, Canada were included in both study periods.

Nasal and throat screening for S. aureus carriage of all eligible TJR patients in the preoperative clinic was implemented as standard of care. Patients who tested positive were contacted and provided with details on the S. aureus decolonization protocol. Decolonization included a standardized treatment protocol of 2% intranasal mupirocin twice daily for five days prior to surgery date (excluding day of surgery), and chlorhexidine gluconate wipes (2%) to be used once daily for 4 days prior to surgery date and on the morning of surgery. Regardless of the colonization status at the visit in the preoperative clinic, all patients were re-swabbed on the day of surgery.

Primary outcome of interest was the rate of deep PJI as per CDC/NHSN at one-year postoperative follow-up. Secondary outcomes included rate of deep PJIs due to S. aureus, adherence to the decolonization protocol, proportion of S. aureus carriers successfully decolonized, and the proportion of patients deemed as non-carriers following preoperative swab subsequently identified as carriers on the day of surgery. A total of 8,505 patients were included in the 5-year control group, and 1,883 during the intervention period, of which 424 (22.5%) were identified as S. aureus carriers.

The deep PJI rate was similar in the two groups, 0.4% (7/1,883) in the intervention group and 0.5% (42/8,505) in the control group (OR 0.75, 95%CI 0.34–1.67, p=0.58). More importantly, we found a significant reduction in PJI due to S. aureus to only one case in the intervention period (0.05%) as compared to 29 cases (0.3%) in the historic control (OR 0.15, 95%CI 0.004–0.94, p=0.0376).

We found a significant reduction in PJIs due to S. aureus by decolonizing S. aureus carriers prior to surgery. However, no significant difference in overall infection rates was observed. In conclusion, routine implementation of active screening for S. aureus and decolonization of carriers before TJR is feasible and helps to reduce PJI due to S. aureus.

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR.

A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant.

The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year VAS pain. PCS-magnification CRC sub-domain was also identified as a significant predictor of KSS/HHS at one-year (median difference 1.3, 95% CI −5.23–0.11, p=0.041). Preoperative VAS pain, Oxford and HHS/KSS scores were significantly inferior in patients who had CRC PCS, abnormal HADS-A, and abnormal HADS-D scores compared to patients with normal scores. At one-year, PCS CRC patients also had significantly inferior VAS pain (p=0.001), Oxford (p < 0 .0001) and KSS/HHS (p=0.025). Abnormal HADS-A and HADS-D patients experienced significantly inferior postoperative VAS pain (HADS-A p=0.025, HADS-D p=0.030), Oxford (HADS-A p=0.001, HADS-D p=0.030), but no difference in KSS/HHS (HADS-A = 0.069, HADS-D = 0.071) compared to patients with normal PCS/HADS scores. However, patients with CRC PCS experienced significantly greater improvement in preoperative to postoperative VAS pain (p < 0 .0001), Oxford (p=0.003) and HHS/KSS (p < 0 .0001). Similarly, patients with abnormal HADS scores showed significant improvement in preoperative to one-year postoperative change scores, as compared to normal patients in VAS pain (HADS-A p=0.011, HADS-D p=0.024), KSS/HHS (HADS-A p=0.017, HADS-D p=0.031), but not Oxford (HADS-A p=0.299, HADS-D p=0.558).

Patients who are anxious, depressed or who pain catastrophize have worse preoperative function and pain. Postoperatively, pain and functional outcomes are also inferior in such patients, however they do experience a significantly greater improvement in outcomes. Furthermore, it appears that rumination and anxiety traits predict pain levels postoperatively. Although these patients report higher levels of pain postoperatively, as compared to preoperative, great improvement can be expected following hip and knee TJR.

The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics.

A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and Lawrence (K-L) scale. Logistic regression was used to assess pattern of relationship between preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% confidence interval (CI) were reported. A secondary quantile regression analysis examined whether a model not restricted to pre-defined PCS and HADS categories would yield comparable results to the logistic regression model described in the primary analysis. P-values less than 0.05 were considered statistically significant.

The sample included 463 TJR patients (178 hips, 285 knees). VAS pain (OR 1.23,95%CI 1.04–1.45) and Oxford score (OR 1.13,95%CI 1.07–1.20) were identified as significant predictors for PCS. The same two variables were the strong predictors for all sub-domains of PCS excluding rumination. Oxford Score was the only significant predictor for abnormal HADS-A (OR 1.10,95%CI 1.04–1.17) while VAS pain (OR 1.27,95%CI 1.02–1.52) and Oxford (OR 1.09,95%CI 1.01–1.17) were significant predictors for abnormal HADS-D. Similar pattern of association for PCS and HADS was observed in the quantile regression model, where larger VAS pain and Oxford scores significantly increased median PCS across all domains. Female gender, younger age or having a higher ASA grade were associated with higher median HADS-A, but unlike in the logistic regression, this association was statistically significant.

Pain catastrophising and emotional disorders generally result in poor functional outcomes in TJR patients. The most important predictor of catastrophising, anxiety/depression is pain and subjective function. At risk patients include those with high preoperative pain with generally good preoperative function, as well as younger females with significant comorbidities. Such patients should be identified, and targeted psychological therapy implemented preoperatively to optimise coping strategies and adaptive behaviour to mitigate inferior TJR outcomes including pain and patient dissatisfaction.