Total knee arthroplasty (TKA) results in a high degree of patient satisfaction, as it provides patients with considerable medium- and long-term benefits in terms of quality of life, pain relief and function. Nevertheless, the literature reports that up to 30% of patients are dissatisfied. This dissatisfaction is directly related to the patients' quality of life, which they deem insufficient. Their quality of life depends on many physical, behavioural, social and psychological factors that are not taken into account by functional outcome scores. After describing the principles of quality of life evaluation after TKA, we will assess the effects of patient-related factors, the surgical technique and postoperative program through an exhaustive review of the literature. Patient expectations after TKA will then be outlined, particularly return to work and return to sports.

Quality of life after total knee arthroplasty.

Objectives To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis. Results A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p Conclusions ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.

https://pmj.bmj.com/content/postgradmedj/93/1106/736.full.pdf

Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis.

Objective To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI). Design Two group parallel, assessor blinded, pragmatic randomised controlled trial. Setting Secondary and tertiary care centres across seven NHS England sites. Participants 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle Interventions Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care. Main outcome measures The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment. Results At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P Conclusions Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification. Trial registration ClinicalTrials.gov NCT01893034.

https://www.bmj.com/content/bmj/364/bmj.l185.full.pdf

Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial.

Two hundred seventy-nine patients undergoing primary unilateral total knee replacement and 280 patients undergoing primary bilateral total knee replacements were reviewed retrospectively. Patients' height, weight, hemoglobin level before donation, hemoglobin level before surgery, autologous donation, number and type of transfusions whether autologous or allogeneic, and hemoglobin at discharge were collected from hospital and clinic records. The average drop in hemoglobin was 3.85 g/dL in the group of patients undergoing unilateral total knee replacement and 5.42 g/dL in the group of patients undergoing bilateral total knee replacements. The preoperative hemoglobin and blood volume seemed to be very strong, statistically significant predictors of transfusion risk in single and bilateral knee replacements. In unilateral total knee replacement, patients with a hemoglobin of greater than 13 g/dL had only an 8% chance of transfusion and if they donated autologous blood, 66% of the blood was wasted. Preoperative anemia was a strong predictor of transfusion risk in patients undergoing unilateral and bilateral total knee replacements and carried a very high allogeneic transfusion exposure risk, even in patients who had donated blood preoperatively. A nomogram was developed using blood volume and predonation hemoglobin to predict transfusion risk and need to predeposit autologous blood in patients undergoing unilateral and bilateral total knee replacements.

Predictors of transfusion risk in elective knee surgery : Methods to reduce the use of allogeneic transfusions

Background:The benefits of hip arthroscopic surgery in the setting of femoroacetabular impingement (FAI) have been well established; however, some patients may experience a greater degree of improv...

https://journals.sagepub.com/doi/pdf/10.1177/2325967119848982

Predictors of Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review:

INTRODUCTION Enhanced recovery programmes (ERPs) are being widely adopted in total knee replacement (TKR) procedures but studies confirming that they have no adverse effects on functional outcomes are lacking. The aim of this study was to compare length of stay, postoperative functional outcome and range of motion at one year postoperatively between patients undergoing TKR with an ERP and those with traditional rehabilitation. METHODS A total of 165 consecutive patients undergoing primary unilateral TKR were included in the study. Overall, 84 patients undergoing TKR with an ERP were compared with a series of 81 patients undergoing primary unilateral TKR with traditional rehabilitation, immediately before the introduction of the ERP. RESULTS The median postoperative length of stay was 3 days in the ERP cohort and 4 in the traditionally rehabilitated cohort (p<0.001). There were no significant differences in the preintervention characteristics of the groups and there was no significant difference in operative time, transfusion or rates of manipulation under anaesthesia. There was no difference in magnitude of improvement in American Knee Society score (p=0.12) or range of motion (p=0.81) between the groups. CONCLUSIONS ERP can reduce length of stay after TKR while offering improvements in knee function equivalent to those experienced by patients undergoing TKR with traditional rehabilitation. Furthermore, ERP can be implemented successfully in the setting of a district general hospital.

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Enhanced recovery programmes can reduce length of stay after total knee replacement without sacrificing functional outcome at one year

The International Hip Outcome Tool 12 (iHOT-12) is a shorter version of the iHOT-33 which measures health related quality of life following treatment of hip disorders in young, active patients. The purpose of this study was identify a PASS threshold for a UK population undergoing hip arthroscopy for intra-articular hip pathology. Data was identified retrospectively from a prospective database of patients undergoing hip arthroscopy under the care of a single surgeon within the date range January 2013 to March 2017. All patients with a diagnosis of femoroacetabular impingment (FAI) undergoing arthroscopic treatment were included. iHOT-12, EuroQol 5D-5 L (EQ-5D-5 L) and a satisfaction questionnaire were available pre and post-operatively. PASS was calculated using an anchor-based approach and receiver operator characteristic (ROC) analysis. 171 patients underwent hip arthroscopy in the study period. Linked longitudinal follow-up data was available for 122 patients (71.3%) at a median of 24.3 months (740 days, interquartile range 576–1047). The PASS threshold for the iHOT-12 was 59.5 (sensitivity 81.1%, specificity 83.9%; area under the curve (AUC) 0.92, 95% CI 0.87–0.97). 64% of patients achieved this score. The median postoperative iHOT-12 score was 72.5 (IQR 44) and the mean change in score was 35 (SD 25, p < 0.001). The EQ-5D Index improved by 0.18 (SD 0.25, p < 0.001) and there was a mean change of 7.67 (SD 24.82) on the EQ-5D VAS (p = 0.001). We report a PASS threshold of the iHOT-12 following hip arthroscopy for FAI as a measurable benchmark for clinicians using this outcome measure.

/pdf/evaluation-of-the-patient-acceptable-symptom-state-following-1cumlm6pcp.pdf

Evaluation of the patient acceptable symptom state following hip arthroscopy using the 12 item international hip outcome tool.

Introduction Although total knee arthroplasty (TKA) is an index procedure for orthopaedic registrars, there is a lack of published research as to the effects of surgery when performed by supervised trainees. The aim of this study was to compare functional outcomes up to five years after primary TKA performed by consultants and trainee surgeons. Methods A retrospective analysis was conducted of prospectively collected data for 609 consecutive patients (339 female, 270 male) undergoing TKA. Patients were assessed preoperatively as well as at 18 months, three years and five years postoperatively, and American Knee Society objective knee and functional scores (AKSK and AKSF) were recorded. Results Surgery was performed by a consultant in 465 cases and a supervised trainee in 144 cases. There were no significant differences between the two groups in preoperative patient characteristics, operative time (p=0.15), transfusion rates (p=0.84), length of stay (p=0.98), manipulation under anaesthesia (p=0.69), or mortality rates at one year (p=0.73) or five years (p=0.81). Postoperatively, the median magnitude of improvement in AKSK (48 points for consultant group vs 45 points for trainee group, p=0.74) and in AKSF (both groups 15, p=0.995) was similar between the groups. AKSK and AKSF scores were similar at all timepoints up to five years following surgery, and there was no difference in the median range of motion (both groups 100°, IQR: 18°) at five years (p=0.43). Conclusions TKA performed by supervised registrars gives functional outcomes that are equivalent to consultant performed TKA, without affecting postoperative range of movement, or increasing operative time, length of stay or transfusion rates. Rates of postoperative MUA and mortality are also comparable.

/pdf/surgery-performed-by-supervised-registrars-does-not-1djarga9w5.pdf

Surgery performed by supervised registrars does not adversely affect medium-term functional outcomes after total knee replacement.

Aims Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study...

Correlations between radiological classification systems and confirmed cartilage loss in severe knee osteoarthritis.

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  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.

Julian F. Maempel

Papers

Enhanced recovery programmes can reduce length of stay after total knee replacement without sacrificing functional outcome at one year

Evaluation of the patient acceptable symptom state following hip arthroscopy using the 12 item international hip outcome tool.

Surgery performed by supervised registrars does not adversely affect medium-term functional outcomes after total knee replacement.

Correlations between radiological classification systems and confirmed cartilage loss in severe knee osteoarthritis.

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