Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients

Background and purpose — Total knee replacement (TKR) is being increasingly performed in elderly patients, yet there is little information on specific requirements and complication rates encountered by this group. We assessed whether elderly patients undergoing TKR had different length of stay, requirements, complication rates, and functional outcomes compared to younger counterparts. Patients and methods — We analyzed prospectively gathered data on 3,144 consecutive primary TKRs (in 2,092 patients aged less than 75 years, 694 patients aged between 75 and 80 years, and 358 patients aged over 80 years at the time of surgery). Results — Incidence of blood transfusion, urinary catheterization, postoperative confusion, cardiac arrhythmia, and 1-year mortality increased with age, even after adjusting for confounding factors, whereas the incidences of chest infection and mortality at 1 month were highest in those aged 75–80. Rates of thromboembolism, prosthetic infection, and revision were similar in the 3 age groups. All groups showed similar substantial improvements in American Knee Society (AKS) knee scores, which were maintained at 5 years. Older patients had smaller improvements in AKS function score, which deteriorated between 3 and 5 years postoperatively, in contrast to the younger group. Interpretation — Elderly people stand to gain considerably from TKR, particularly in terms of pain relief, and they should not be denied surgery based solely on age. However, they should be warned that they can expect a longer length of stay, a higher requirement for blood transfusion and/or urinary catheterization, and more medical complications postoperatively. Mortality was also higher in the older age groups. The risks have been quantified to assist in perioperative counselling, informed consent, and healthcare planning.peer-reviewe

Predictors of excellent early outcome after total hip arthroplasty

<p>Abstract</p> <p>Background</p> <p>Not all patients gain the same degree of improvement from total hip replacement and the reasons for this are not clear. Many investigators have assessed predictors of general outcome after hip surgery. This study is unique in its quest for the predictors of the best possible early outcome.</p> <p>Methods</p> <p>We prospectively collected data on 1318 total hip replacements. Prior to surgery patient characteristics, demographics and co-morbidities were documented. Hip function and general health was assessed using the Harris Hip score (HHS) and the Short-Form 36 respectively. The HHS was repeated at three years. We took a maximal HHS of 100 to represent an excellent outcome (102 patients). Multiple logistic regression analysis was used to identify independent predictors of excellent outcome.</p> <p>Results</p> <p>The two strongest predictive factors in achieving an excellent result were young age and a high pre-operative HHS (p = 0.001).</p> <p>Conclusions</p> <p>It was the young and those less disabled from their arthritis that excelled at three years. When making a decision about the timing of hip arthroplasty surgery it is important to take into account the age and pre-operative function of the patient. Whether these patients continue to excel however will be the basis of future research.</p

Excellent survival and good outcomes at 15 years using the Press Fit Condylar Sigma total knee replacement

Background: We report 15-year survival, clinical and radiographic follow-up data for the Press Fit Condylar Sigma total knee replacement (PFC Sigma TKR). Methods: Between October 1998 and October 1999, 235 consecutive TKRs were performed in 203 patients. Patients were reviewed at a specialist nurse-led clinic prior to surgery, and at five, eight-to-ten and 15 years postoperatively. Clinical outcomes, including Knee Society Score (KSS), were recorded prospectively at each clinic visit, and radiographs were obtained. Results: Of our initial cohort, 99 patients (118 knees) were alive at 15 years, and 31 patients (34 knees) were lost to follow-up. 13 knees (5.5%) were revised; five (2.1%) for infection, seven (3%) for instability and one (0.4%) for aseptic loosening. Cumulative survival with the end-point of revision for any reason was 92.3% at 15 years, and with revision for aseptic failure as the end-point was 94.4%. The mean KSS knee score was 77.4 (33 to 99) at 15 years, compared with 31.7 (2 to 62) preoperatively. Of 71 surviving knees for which X-rays were available, 12 (16.9%) had radiolucent lines and one (1.4%) demonstrated clear radiographic evidence of loosening. Conclusion: The PFC Sigma TKR represents a durable, effective option for patients undergoing knee arthroplasty, with excellent survival and good clinical and radiographic outcomes at 15 years.PostprintPeer reviewe

A postal survey of current thromboprophylactic practices of consultant orthopaedic surgeons in the treatment of fracture of the hip

Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature.</p

Clinical and radiologic outcome of total hip arthroplasty performed by trainee compared with consultant orthopedic surgeons

Data were prospectively collected on 139 total hip arthroplasties (THAs) performed by supervised specialist registrars (residents) and 397 THAs performed by consultants. The Harris Hip Score and data on comorbidity, blood loss, transfusion requirements, re-operation, dislocation, and death were recorded. Radiologic assessment of acetabular and femoral component alignment and cementation was made using 114 trainee radiographs that were available for review at 6 months. These were compared with 114 matched consultant radiographs. At 18 months, there was no significant difference in clinical outcome. Acetabular anteversion was significantly less in trainee-performed THA. This article reveals no difference in the short-term clinical results of THA performed by consultants and supervised trainees. There is radiographic evidence of decreased anteversion of the acetabulum by trainees, although the dislocation rates are not different. Our results show that quality can be maintained while training juniors to perform surgery.</p

Range of movement correlates with the Oxford knee score after total knee replacement:A prediction model and validation

BACKGROUND: Patient reported outcome measures are widely used in the evaluation of outcomes after Total Knee Replacement (TKR) in joint registries and large studies. The aim of this study was to assess the relationship between the Oxford knee score (OKS) and range of motion (ROM) after TKR, and to construct and validate prediction models of ROM from the measured OKS.METHODS: Eight hundred sixty patients reviewed five years postoperatively and 273 patients reviewed nine to 10 years postoperatively completed an OKS. Of these, 808 (94%) and 226 (83%) patients, respectively, had a complete dataset (knee extension and ROM) and formed the study cohort.RESULTS: Regression analysis demonstrated a significant correlation between the OKS and ROM (r=0.38, p&lt;0.001) after adjusting for other confounding variables (age, sex, body mass index, and knee extension). A prediction model was constructed and validated using a second cohort of 226 patients at nine to 10 years after their TKR. Intraclass correlation demonstrated good reliability (r=0.60, 95% CI 0.47 to 0.69) between predicted and actual measured ROM for this group. However, when the OKS is used in isolation the reliability of the predicted ROM is diminished (intraclass correlation r=0.41, 95% CI 0.24 to 0.55).CONCLUSIONS: The OKS is an independent predictor of ROM after TKR. It is also possible to predict ROM from the OKS, but the reliability of this is improved when other independent predictors such as age, gender, body mass index (BMI) and degree of knee extension are also acknowledged.</p

Range of movement correlates with the Oxford knee score after total knee replacement:A prediction model and validation

BACKGROUND: Patient reported outcome measures are widely used in the evaluation of outcomes after Total Knee Replacement (TKR) in joint registries and large studies. The aim of this study was to assess the relationship between the Oxford knee score (OKS) and range of motion (ROM) after TKR, and to construct and validate prediction models of ROM from the measured OKS.METHODS: Eight hundred sixty patients reviewed five years postoperatively and 273 patients reviewed nine to 10 years postoperatively completed an OKS. Of these, 808 (94%) and 226 (83%) patients, respectively, had a complete dataset (knee extension and ROM) and formed the study cohort.RESULTS: Regression analysis demonstrated a significant correlation between the OKS and ROM (r=0.38, p&lt;0.001) after adjusting for other confounding variables (age, sex, body mass index, and knee extension). A prediction model was constructed and validated using a second cohort of 226 patients at nine to 10 years after their TKR. Intraclass correlation demonstrated good reliability (r=0.60, 95% CI 0.47 to 0.69) between predicted and actual measured ROM for this group. However, when the OKS is used in isolation the reliability of the predicted ROM is diminished (intraclass correlation r=0.41, 95% CI 0.24 to 0.55).CONCLUSIONS: The OKS is an independent predictor of ROM after TKR. It is also possible to predict ROM from the OKS, but the reliability of this is improved when other independent predictors such as age, gender, body mass index (BMI) and degree of knee extension are also acknowledged.</p

Metaphyseal Sleeves for Revision Total Knee Arthroplasty:Good Short-Term Outcomes

Metaphyseal sleeve prostheses have shown promising results in the management of bone defects at revision TKA. We present a study of their use in aseptic revision TKA. Thirty-five revisions were included in 34 patients with wear or aseptic loosening indicated in 71% of cases. The majority of cases (63%) were AORI grade 2 or greater on the tibia or femur. Knee Society scores were excellent or good in 83% of patients with the same percentage having no or only mild pain. One patient suffered a sleeve-related complication with femoral condylar fractures three years postoperatively; these united with good outcomes. All radiographs were satisfactory; no patient required a further revision. We report good outcomes with the use of metaphyseal sleeves in revision TKA.</p

Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients

BACKGROUND AND PURPOSE: Total knee replacement (TKR) is being increasingly performed in elderly patients, yet there is little information on specific requirements and complication rates encountered by this group. We assessed whether elderly patients undergoing TKR had different length of stay, requirements, complication rates, and functional outcomes compared to younger counterparts. PATIENTS AND METHODS: We analyzed prospectively gathered data on 3,144 consecutive primary TKRs (in 2,092 patients aged less than 75 years, 694 patients aged between 75 and 80 years, and 358 patients aged over 80 years at the time of surgery). RESULTS: Incidence of blood transfusion, urinary catheterization, postoperative confusion, cardiac arrhythmia, and 1-year mortality increased with age, even after adjusting for confounding factors, whereas the incidences of chest infection and mortality at 1 month were highest in those aged 75–80. Rates of thromboembolism, prosthetic infection, and revision were similar in the 3 age groups. All groups showed similar substantial improvements in American Knee Society (AKS) knee scores, which were maintained at 5 years. Older patients had smaller improvements in AKS function score, which deteriorated between 3 and 5 years postoperatively, in contrast to the younger group. INTERPRETATION: Elderly people stand to gain considerably from TKR, particularly in terms of pain relief, and they should not be denied surgery based solely on age. However, they should be warned that they can expect a longer length of stay, a higher requirement for blood transfusion and/or urinary catheterization, and more medical complications postoperatively. Mortality was also higher in the older age groups. The risks have been quantified to assist in perioperative counselling, informed consent, and healthcare planning