A prospective cohort study investigating functional recovery in patients with osteoarthritis following total hip arthroplasty using a direct anterior versus direct lateral surgical approach

We used a quasi-randomized cohort study to investigate whether there are differences in early functional recovery between patients who undergo total hip arthroplasty using a direct anterior (DA) or direct lateral (DL) surgical approach. We found significant differences in favour of the DA group for many functional outcomes including: gait velocity, stride length, operative limb single-limb support, single-limb support symmetry and time to complete the Timed Up and Go. Our primary outcome, gait velocity, was significantly greater in the DA group at discharge, two weeks and six weeks postoperative with adjusted mean differences of 0.12m/s, 0.15m/s and 0.17m/s respectively. There was no difference between the groups at any time point for quality of life or pain. The DA approach to THA offers better early functional outcomes than the DL group

A protocol for a randomized controlled trial investigating the safety and cost-effectiveness of outpatient total hip arthroplasty

© 2020 The Author(s). Background: A significant proportion of the overall cost of total hip arthroplasty (THA) results from the inpatient hospital stay following the procedure. Considering the substantial and increasing number of these procedures performed annually, shifting to an outpatient model of care where the patient is discharged home the same day as their surgery represents a potential for significant cost savings. The potential significant impact of an outpatient care model on constrained healthcare budgets and lack of high-quality evidence regarding its effectiveness warrants a rigorous comparative trial. The purpose of this prospective, randomized controlled trial is to evaluate outpatient care pathways for THA. Specifically, our objectives are to compare the rate of serious adverse events and estimate the cost-effectiveness of outpatient compared to standard inpatient THA. Methods: We will include patients undergoing primary THA whom have an American Society of Anaesthetists status equal to or less than three, live within a 60-min driving distance of the institution and have an adult to accompany them home postoperatively and stay with them overnight. Consenting patients will be randomized to be discharged on the same day as surgery, as outpatients, or as inpatients according to standard of care (minimum of one night in hospital) using a modified Zelen consent model. The primary outcome measure is the incidence of serious adverse events at 30 days postoperative. Participants and their caregivers will complete secondary outcomes measures at each follow-up visit including patient-reported outcome measures and self-reported cost questionnaires. Discussion: This protocol is the first randomized trial to use blinding to evaluate outpatient THA compared to standard overnight stay and first to prospectively perform a full economic evaluation. It is also the first adequately powered trial to prospectively assess the safety of outpatient THA. Successful completion of this study could have the potential to provide clinical evidence for the role of outpatient THA in current practice. Trial registration: This study was retrospectively registered on ClinicalTrials.gov (NCT03026764) on March 9th, 2016

Perioperative gait analysis after total hip arthroplasty: Does outpatient surgery compromise patient outcomes?

Background: There has been a continuing trend towards decreasing the length of hospital stay for patients undergoing total hip arthroplasty (THA). Outpatient procedures, discharging patients on the same day as surgery, have now become possible yet little research has been done to examine the impact this might have on patients during early recovery. We aimed to investigate the impact of discharge time on gait and patient-reported outcomes in the early post-operative period. Methods: We measured gait velocity, stride length, single-limb support and single-limb support symmetry preoperatively, at discharge from the hospital, and two-, six- and 12-weeks postoperatively. Participants also completed the Timed Up and Go and a series of questionnaires (WOMAC, SF-12, Harris Hip Score and pain VAS) at each visit. Results: Thirty-six participants undergoing a direct anterior THA with a single surgeon were enrolled in this study. Sixteen participants were discharged on the same day as surgery (outpatient group), while 20 stayed at least one night in hospital (inpatient group). We found pain at time of discharge to be significantly lower in the outpatient group compared to the inpatient group (p=0.04). We found no other differences between the groups for any gait, patient-reported or surgical outcomes (p\u3c0.05). Conclusion: Following a direct anterior total hip arthroplasty, patients who stayed overnight had significantly more pain at discharge than those discharged as outpatients. There were no differences in gait or patient-reported outcomes between groups. Interdisciplinary Reflection: This study incorporates aspects of kinesiology, surgery, rehabilitation and health policy

Implementation of outpatient total joint arthroplasty in canada: Where we are and where we need to go

© 2020 Zomar et al. Total joint arthroplasties (TJA) are successful procedures for the treatment of end-stage hip and knee arthritis. Length of stay in hospitals after these procedures has been steadily decreasing over time, with outpatient procedures (discharge on the same day as surgery) introduced in the US within the last 20 years. Reducing length of stay after TJA can provide cost savings. Centres in Canada have started to utilize outpatient TJA procedures, but we have identified some barriers that may have limited their implementation. We have summarized the current literature for outpatient TJA and discussed potential solutions for the current barriers

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. Objectives We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation. Data sources PubMed, CINAHL, Scopus; inception to January 2019. Eligibility criteria Randomised clinical trials (RCT), cohort studies, case series. Design We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO 2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models. Results Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO 2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (-3.56 beats per minute; 95% CI -5.60 to -1.52) and DBP (-4.10 mm Hg; 95% CI -4.82 to -3.38) and no change in SBP (-0.36 mm Hg; 95% CI -3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI -0.11 to 0.85). Within-group differences were also small to moderate. Conclusions In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA. PROSPERO registration number CRD42018087859

Reducing Length of Stay After Total Hip and Knee Arthroplasty: Assessing Cost-Effectiveness, Caregiver Involvement and Surgical Approach

Purpose The overall purpose of this dissertation was to evaluate factors related to reducing length of stay after total hip and knee arthroplasty (THA and TKA). Methods Study 1 was a randomized controlled trial (RCT) to investigate the cost-effectiveness of outpatient THA compared to standard overnight stay. Study 2 was a prospective cohort study to assess patient- and caregiver-related factors and how they may relate to caregiver strain and level of assistance when caring for patients undergoing THA and TKA. Finally, Study 3 was a 2x2 factorial RCT to compare the trajectory of early functional recovery between the medial parapatellar and midvastus surgical approaches for TKA. The purpose of Study 3 was to determine whether the choice of surgical approach should be controlled for a future randomized trial assessing the cost-effectiveness of outpatient TKA. Results For our first study, we found standard overnight stay was dominated by outpatient THA from both healthcare payer (HCP) and societal cost perspectives. Our net benefit analyses found outpatient THA to be cost-effective at all willingness-to-pay values from an HCP perspective and values of $500 or more from a societal perspective. For our second study, our model of caregiver strain found the amount of assistance provided by caregivers to be a positive predictor, and female patient sex and caregiver age to be negative predictors. Our model of caregiver assistance found length of stay to be a positive predictor and time (post- versus pre-surgery) and female patient and caregiver sex to be negative predictors. For our third study, we found the trajectory of recovery of pain within the first two weeks after surgery and stride length to have significant group by time interactions. We also found baseline outcomes to be a consistent predictor of post-surgery recovery. Conclusions Reducing the length of stay in hospital after THA and TKA procedures can be cost-effective, does not increase caregiver strain and is associated with a reduction in the amount of assistance provided by caregivers. We’ve also provided evidence for the use of either of two commonly used surgical approaches for TKA for a future randomized trial to further explore outpatient arthroplasty

Management of long bone fractures and traumatic hip dislocations in paediatric patients: study protocol for a prospective global multicentre observational cohort registry

ABSTRACT Introduction Management controversy and clinical equipoise exist in treatments of long bone fractures and traumatic hip dislocation in paediatric patients due to the lack of high-quality clinical evidence. This protocol describes the effort of a large prospective global multicentre cohort study (registry) aiming at providing quality data to assist evidence-based treatment decisionmaking. Methods and analysis Eligible paediatric patients (N=750–1000) with open physes suffering from proximal humerus fractures, distal humerus fractures, proximal radius fractures, forearm shaft fractures, traumatic hip dislocations, femoral neck fractures or tibial shaft fractures will be recruited over a period of 24–36 months. Hospitalisation and treatment details (including materials and implants) will be captured in a cloudbased, searchable database. Outcome measures include radiographic assessments, clinical outcomes (such as range of motion, limb length discrepancies and implant removal), patient-reported outcomes (Patient Reported Outcomes Of Fracture, Patient-Reported Outcomes Measurement Information System (PROMIS) and EuroQol5D (EQ-5D-Y)) and adverse events. Aside from descriptive statistics on patient demographics, baseline characteristics, types of fractures and adverse event rates, research questions will be formulated based on data availability and quality. A statistical analysis plan will be prepared before the statistical analysis. Ethics and dissemination Ethics approval will be obtained before patients are enrolled at each participating site. Patient enrolment will follow an informed consent process approved by the responsible ethics committee. Peer-reviewed publication is planned to disseminate the study results. Trial registration number NCT04207892

A randomised trial comparing spatio-temporal gait parameters after total hip arthroplasty between the direct anterior and direct lateral surgical approaches

© The Author(s) 2018. Introduction: Total hip arthroplasty (THA) is a successful procedure for relieving symptoms of severe osteoarthritis. Surgical approach is a key factor in early recovery and although controversial, little has been written about the direct anterior (DA) approach using objective early measures. Methods: 78 participants were prospectively enrolled to undergo a THA through either a DA or direct lateral (DL) surgical approach. Outcome measures were collected preoperatively and at discharge from the hospital, and 2-, 6- and 12-weeks. Outcome measures included the GAITRite® system to measure gait velocity, stride length, single-limb support and single-limb support symmetry. At each time point participants also completed the Timed Up and Go (TUG), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short-Form Survey (SF-12), Harris Hip Score, and pain visual analog scale (VAS). Results: We found statistically significant differences in gait velocity at discharge, 2-weeks and 6-weeks in favour of the DA group (all p \u3c 0.01). We also found significant differences in favour of the DA group for single-limb support symmetry at 6-weeks (p \u3c 0.01) and 12-weeks (p \u3c 0.01). The time to complete the TUG test was also significantly shorter in the DA group at 2-weeks (p \u3c 0.01) and 6-weeks (p \u3c 0.01) compared to the DL group. However, there were no statistically significant differences in any of the patient-reported outcomes. Conclusion: The DA surgical approach was found to offer significant early advantages in function compared to the DL group, with no differences in quality of life or pain

Risk Factor Analysis for Growth Arrest in Paediatric Physeal Fractures—A Prospective Study

Background: Fractures through the physis account for 18–30% of all paediatric fractures, leading to growth arrest in up to 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. Methods: This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients ≤ 18 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators, and radiographic data were collected at baseline, during healing, and at one- and two-years post-injury. Results: A total of 332 patients had at least six months of follow-up or a diagnosis of growth arrest within six months of injury. In a comparison analysis, patients who developed growth arrest were more likely to be older (12.8 years vs. 9.4 years) and injured on the right side (53.0% vs. 45.7%). Initial displacement and angulation rates were higher in the growth arrest group (59.0% vs. 47.8% and 47.0% vs. 38.8%, respectively), but the amount of angulation was similar (27.0° vs. 28.4°). Rates of growth arrest were highest in distal femoral fractures (86%). Conclusions: The incidence of growth arrest in this patient population appears higher than the past literature reports at 30.1%. However, there may be variances in diagnostic criteria for growth arrest, and the true incidence may be lower. A number of patients were approaching skeletal maturity, and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine risk factors, incidence, and true clinical impact of growth arrest when it does occur.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofOrthopaedics, Department ofReviewedFacultyResearche