Session 10: Knee II
Torsdag den 24. oktober
13:30 - 15:00
Lokale: Centersal
Chairmen: Søren Rytter og Frank Madsen
Peter Skrejborg, Kristian Kjær Petersen, Mogens Laursen, Lars Arendt-Nielsen
Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
Background: Assessing pain by use of VAS or NRS scales have been used widely in clinical and research settings in which a quick index of pain intensity is required and to which a numerical value can be assigned. The literature suggests that health professionals have a tendency to underestimate pain when performing clinical assessment of pain.
Purpose / Aim of Study: The aim of the analyze was to investigate the difference in health professional and patient assessed pain score.
Materials and Methods: Secondary analyze of data from a drug- study were the participants Pain at rest were assessed on a VAS scale by a nurse at inclusion and by the patients themselves in connection with different questionnaires prior to knee or hip replacement surgery. Paired samples T-Test was used to calculate any difference.
Findings / Results: 341 patients scheduled for Total Knee or Hip Replacement were presurgical assessed. There was found a significant difference in mean VAS on 1.67 (2.24), p<0.001. Mean VAS assessed by nurses were 1.78 (2.14) and by patients 3.44 (2.24), with a moderate correlation between the 2 variables (r=0.432, p<0.001).
Conclusions: The current study found that there was a discrepancy between health professional and patient assessed pain measured by VASs at patients scheduled for knee hip replacement surgery with clear underestimating of the pain by the health professionals.
Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark; Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
Background: Assessing pain by use of VAS or NRS scales have been used widely in clinical and research settings in which a quick index of pain intensity is required and to which a numerical value can be assigned. The literature suggests that health professionals have a tendency to underestimate pain when performing clinical assessment of pain.
Purpose / Aim of Study: The aim of the analyze was to investigate the difference in health professional and patient assessed pain score.
Materials and Methods: Secondary analyze of data from a drug- study were the participants Pain at rest were assessed on a VAS scale by a nurse at inclusion and by the patients themselves in connection with different questionnaires prior to knee or hip replacement surgery. Paired samples T-Test was used to calculate any difference.
Findings / Results: 341 patients scheduled for Total Knee or Hip Replacement were presurgical assessed. There was found a significant difference in mean VAS on 1.67 (2.24), p<0.001. Mean VAS assessed by nurses were 1.78 (2.14) and by patients 3.44 (2.24), with a moderate correlation between the 2 variables (r=0.432, p<0.001).
Conclusions: The current study found that there was a discrepancy between health professional and patient assessed pain measured by VASs at patients scheduled for knee hip replacement surgery with clear underestimating of the pain by the health professionals.
Anders Christian Laursen, Ashir Ejaz, Andreas Kappel, Poul Torben Nielsen, Mogens Laursen
Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital
Background: Open-wedge high tibia osteotomy (OW-HTO) is a painful procedure requiring intensive post-operative pain management. There are no high quality evidence to inform clinical practice about the most effective pain management approach. Current practice for pain management may include local infiltration analgesia (LIA), femoral nerve block (FNB), oral or intravenous opioid treatment, or typically a combination.
Purpose / Aim of Study: The aim of this randomized, controlled trial was to compare the effects of LIA versus FNB on morphine consumption during the first 48 hours, in patients undergoing OW-HTO. The hypothesis was that FNB would be associated with lower opioid consumption than LIA.
Materials and Methods: 64 patients undergoing OW-HTO were randomized to receive bolus FNB (Group F) or LIA (Group L). Primary outcome was measured by adjuvant opioid consumption, secondary measures included pain intensity rating on a numerical scale, adverse effects, and time to discharge.
Findings / Results: All patients received adjuvant opioid treatment, but only few in large amounts. We found no difference in opioid consumption between the groups. 7 patients reported severe pain (NRS > 7) during the active treatment. We observed no differences on length of stay, and the number of adverse effects was low, 2 in each groups.
Conclusions: There were no clinical or significant difference between LIA and FNB on morphine consumption. Neither treatment was associated with significant side effects. As standard treatment, we recommend local infiltration analgesia, due to lower technical requirements and cost, and avoidance of motor function impairment and peripheral nerve injury.
Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital; Department of Orthopedics, Aalborg University Hospital
Background: Open-wedge high tibia osteotomy (OW-HTO) is a painful procedure requiring intensive post-operative pain management. There are no high quality evidence to inform clinical practice about the most effective pain management approach. Current practice for pain management may include local infiltration analgesia (LIA), femoral nerve block (FNB), oral or intravenous opioid treatment, or typically a combination.
Purpose / Aim of Study: The aim of this randomized, controlled trial was to compare the effects of LIA versus FNB on morphine consumption during the first 48 hours, in patients undergoing OW-HTO. The hypothesis was that FNB would be associated with lower opioid consumption than LIA.
Materials and Methods: 64 patients undergoing OW-HTO were randomized to receive bolus FNB (Group F) or LIA (Group L). Primary outcome was measured by adjuvant opioid consumption, secondary measures included pain intensity rating on a numerical scale, adverse effects, and time to discharge.
Findings / Results: All patients received adjuvant opioid treatment, but only few in large amounts. We found no difference in opioid consumption between the groups. 7 patients reported severe pain (NRS > 7) during the active treatment. We observed no differences on length of stay, and the number of adverse effects was low, 2 in each groups.
Conclusions: There were no clinical or significant difference between LIA and FNB on morphine consumption. Neither treatment was associated with significant side effects. As standard treatment, we recommend local infiltration analgesia, due to lower technical requirements and cost, and avoidance of motor function impairment and peripheral nerve injury.
Daan Koppens, Søren Rytter, Stig Munk, Jesper Dalsgaard, Ole Gade Sørensen, Torben Bæk Hansen, Maiken Stilling
Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Aalborg Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aathus Universitetshospital
Background: Peri-prosthetic bone mineral density (BMD) may influence implant fixation and subsequent loosening. Unicompartmental knee arthroplasty (UKA) aims to restore normal knee kinematics and thereby preserve peri-prosthetic BMD.
Purpose / Aim of Study: We studied the influence of systemic and peri- prosthetic BMD in 4 Regions of Interest (ROI) of the proximal tibia on migration of the tibial component of cemented medial UKA.
Materials and Methods: Patients were allocated to a mobile-bearing UKA or a fixed-bearing UKA. Preoperatively patients were dichotomized in a normal BMD group (n = 37) and a low BMD group (n = 28) according to WHO criteria. Dual X-ray absorptiometry (DXA) scans were obtained before surgery, 7 days after surgery, and at 4, 12, and 24 months. Stereo-radiographs were obtained post-operatively, and at 4, 12, and 24 months.
Findings / Results: Patients with normal systemic BMD had a 11-15% higher BMD in all ROIs compared to patients with low systemic BMD throughout follow-up. Over time, a decrease in peri-prosthetic BMD was seen for both groups. Patient’s operated knees and contralateral knees showed a similar reduction in BMD in all ROIs between pre-operative and 24 months. Between 12 and 24 months, the normal BMD group migrated (MTPM) 0.03 mm (95% CI -0.01; 0.08) and the low BMD group migrated 0.02 mm (CI -0.03; 0.07). Migration over time was not influenced by peri-prosthetic BMD.
Conclusions: Migration of cemented medial tibial UKA was low until 24 months and was affected by neither preoperative systemic BMD nor by postoperative change in peri-prosthetic BMD. This suggests good long-term fixation despite an index difference in proximal tibial BMD.
Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Aalborg Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aathus Universitetshospital
Background: Peri-prosthetic bone mineral density (BMD) may influence implant fixation and subsequent loosening. Unicompartmental knee arthroplasty (UKA) aims to restore normal knee kinematics and thereby preserve peri-prosthetic BMD.
Purpose / Aim of Study: We studied the influence of systemic and peri- prosthetic BMD in 4 Regions of Interest (ROI) of the proximal tibia on migration of the tibial component of cemented medial UKA.
Materials and Methods: Patients were allocated to a mobile-bearing UKA or a fixed-bearing UKA. Preoperatively patients were dichotomized in a normal BMD group (n = 37) and a low BMD group (n = 28) according to WHO criteria. Dual X-ray absorptiometry (DXA) scans were obtained before surgery, 7 days after surgery, and at 4, 12, and 24 months. Stereo-radiographs were obtained post-operatively, and at 4, 12, and 24 months.
Findings / Results: Patients with normal systemic BMD had a 11-15% higher BMD in all ROIs compared to patients with low systemic BMD throughout follow-up. Over time, a decrease in peri-prosthetic BMD was seen for both groups. Patient’s operated knees and contralateral knees showed a similar reduction in BMD in all ROIs between pre-operative and 24 months. Between 12 and 24 months, the normal BMD group migrated (MTPM) 0.03 mm (95% CI -0.01; 0.08) and the low BMD group migrated 0.02 mm (CI -0.03; 0.07). Migration over time was not influenced by peri-prosthetic BMD.
Conclusions: Migration of cemented medial tibial UKA was low until 24 months and was affected by neither preoperative systemic BMD nor by postoperative change in peri-prosthetic BMD. This suggests good long-term fixation despite an index difference in proximal tibial BMD.
Julius Tetens Hald, Jacob Fyhring Mortensen, Odgaard Anders
Orthopedic, Copenhagen University Hospital Herlev-Gentofte; Orthopedic, Copenhagen University Hospital Herlev-Gentofte; Orthopedic, Copenhagen University Hospital Herlev-Gentofte
Background: Recent technological advances with inertial sensors, have made gait analysis possible. Previous studies have shown that it is possible to use this technology for assessing pre- and postoperative knee-status for knee arthroplasty patients and that gait-analysis could become a routine method of evaluating knee-performance in Orthopedic departments.
Purpose / Aim of Study: The purpose of this study is to investigate the gait patterns in a population of knee arthroplasty patients participating in a double-blinded RCT study comparing medial Oxford and total knee arthroplasty (mUKA vs. TKA).
Materials and Methods: 14 patients were included prospectively. They had all been diagnosed with isolated antero-medial OA. 7 were randomized to UKA and 7 to TKA. The participants were measured with inertial sensors on a treadmill pre-operatively to arthroplasty and 4 months postoperatively. Participants were examined at level and uphill walking at their self- determined comfortable speed and maximal speed. Average gait cycles were produced, and 36 gait-parameters were calculated using our own algorithms in R. We used non- parametric tests to identify differences between measurements. A p-value of < 0.1 was considered significant because of the explorative nature of the study.
Findings / Results: We found the greatest differences in gait between the pre- and postoperative group, at level walking, comfortable speed. 16 of 36 parameters were significantly different after arthroplasty. Improvements were seen in spatiotemporal, angular, angular velocity, angular acceleration and variability parameter categories. When comparing UKA with TKA we found the greatest differences at uphill walking, maximal speed. In this setting, 10 of 36 parameters were significantly different. UKAs had greater improvements in these same categories.
Conclusions: We found a clear postoperative improvement in gait four months after arthroplasty. Uphill walking seemed to highlight differences between the gait of UKAs and TKAs. Our findings suggest that UKAs improve their gait-pattern more than TKAs.
Orthopedic, Copenhagen University Hospital Herlev-Gentofte; Orthopedic, Copenhagen University Hospital Herlev-Gentofte; Orthopedic, Copenhagen University Hospital Herlev-Gentofte
Background: Recent technological advances with inertial sensors, have made gait analysis possible. Previous studies have shown that it is possible to use this technology for assessing pre- and postoperative knee-status for knee arthroplasty patients and that gait-analysis could become a routine method of evaluating knee-performance in Orthopedic departments.
Purpose / Aim of Study: The purpose of this study is to investigate the gait patterns in a population of knee arthroplasty patients participating in a double-blinded RCT study comparing medial Oxford and total knee arthroplasty (mUKA vs. TKA).
Materials and Methods: 14 patients were included prospectively. They had all been diagnosed with isolated antero-medial OA. 7 were randomized to UKA and 7 to TKA. The participants were measured with inertial sensors on a treadmill pre-operatively to arthroplasty and 4 months postoperatively. Participants were examined at level and uphill walking at their self- determined comfortable speed and maximal speed. Average gait cycles were produced, and 36 gait-parameters were calculated using our own algorithms in R. We used non- parametric tests to identify differences between measurements. A p-value of < 0.1 was considered significant because of the explorative nature of the study.
Findings / Results: We found the greatest differences in gait between the pre- and postoperative group, at level walking, comfortable speed. 16 of 36 parameters were significantly different after arthroplasty. Improvements were seen in spatiotemporal, angular, angular velocity, angular acceleration and variability parameter categories. When comparing UKA with TKA we found the greatest differences at uphill walking, maximal speed. In this setting, 10 of 36 parameters were significantly different. UKAs had greater improvements in these same categories.
Conclusions: We found a clear postoperative improvement in gait four months after arthroplasty. Uphill walking seemed to highlight differences between the gait of UKAs and TKAs. Our findings suggest that UKAs improve their gait-pattern more than TKAs.
Daan Koppens, Maiken Stilling, Torben Bæk Hansen
Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro
Background: The fixed-bearing Sigma medial unicompartmental knee arthroplasty (UKA) has shown a low 7-year revision rate (5.5-6%) in the national registries of England and Australia. A previous radiostereometric analysis (RSA) study with early follow-up showed low implant migration and good clinical outcome (Koppens, Stilling et al. 2018). However, 30% of tibial components showed continuous migration, indicating a risk of loosening.
Purpose / Aim of Study: To evaluate mid-term migration of the tibial component of the Sigma UKA on the same cohort.
Materials and Methods: Between December 2012 and December 2013, 45 cemented, uncoated, fixed-bearing medial Sigma UKA were implanted in 45 patients (21 male; mean age 63 years; SD 9.7). Stereoradiographs were obtained postoperatively, at 4, 12, 24, and 60 months after surgery. Model-based RSA was used to analyse migration (MTPM) of the tibial components. A sub-analysis was performed, classifying components as stable (difference MTPM 12-24 months < 0.02 mm) (n=26) or continuously migrating (difference MTPM 12-24 months > 0.02 mm) (n=11). Clinical outcome was obtained with Oxford Knee Score (OKS) preoperatively, and at 4, 12, 24, and 60 months.
Findings / Results: The cohort showed some initial migration of 0.10 mm (95% CI 0.05; 0.17) between 12 and 24 months and stabilized afterwards. No migration was seen between 24 and 60 months. Sub-analysis showed 0.05 mm (95% CI 0.00; 0.11) migration in the stable group and 0.52 mm (95%CI 0.33; 0.76) migration in the continuously migrating group until 24 months. Stabilization occurred between 24 and 60 months, the stable group migrated 0.04 mm (95% CI -0.03; 0.13) and continuously migrating group migrated 0.04 mm (95% CI -0.21; 0.37). OKS improved with 14.3 (95% CI 11.6; 16.9) at 4 months after surgery, and this improvement remained throughout follow-up. Similar OKS was seen between the stable and continuously migrating group. There were 3 revisions, one due to aseptic loosening of the tibial component.
Conclusions: At mid-term, the Sigma UKA tibial components were well-fixed and stable as measured by RSA, indicating low risk of long-term aseptic loosening.
Ortopædkirurgisk afdeling, Regionshospital Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Regionshospital Holstebro
Background: The fixed-bearing Sigma medial unicompartmental knee arthroplasty (UKA) has shown a low 7-year revision rate (5.5-6%) in the national registries of England and Australia. A previous radiostereometric analysis (RSA) study with early follow-up showed low implant migration and good clinical outcome (Koppens, Stilling et al. 2018). However, 30% of tibial components showed continuous migration, indicating a risk of loosening.
Purpose / Aim of Study: To evaluate mid-term migration of the tibial component of the Sigma UKA on the same cohort.
Materials and Methods: Between December 2012 and December 2013, 45 cemented, uncoated, fixed-bearing medial Sigma UKA were implanted in 45 patients (21 male; mean age 63 years; SD 9.7). Stereoradiographs were obtained postoperatively, at 4, 12, 24, and 60 months after surgery. Model-based RSA was used to analyse migration (MTPM) of the tibial components. A sub-analysis was performed, classifying components as stable (difference MTPM 12-24 months < 0.02 mm) (n=26) or continuously migrating (difference MTPM 12-24 months > 0.02 mm) (n=11). Clinical outcome was obtained with Oxford Knee Score (OKS) preoperatively, and at 4, 12, 24, and 60 months.
Findings / Results: The cohort showed some initial migration of 0.10 mm (95% CI 0.05; 0.17) between 12 and 24 months and stabilized afterwards. No migration was seen between 24 and 60 months. Sub-analysis showed 0.05 mm (95% CI 0.00; 0.11) migration in the stable group and 0.52 mm (95%CI 0.33; 0.76) migration in the continuously migrating group until 24 months. Stabilization occurred between 24 and 60 months, the stable group migrated 0.04 mm (95% CI -0.03; 0.13) and continuously migrating group migrated 0.04 mm (95% CI -0.21; 0.37). OKS improved with 14.3 (95% CI 11.6; 16.9) at 4 months after surgery, and this improvement remained throughout follow-up. Similar OKS was seen between the stable and continuously migrating group. There were 3 revisions, one due to aseptic loosening of the tibial component.
Conclusions: At mid-term, the Sigma UKA tibial components were well-fixed and stable as measured by RSA, indicating low risk of long-term aseptic loosening.
Mette Mikkelsen, Kirill Gromov, Anders Troelsen
Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre
Background: When implementing new procedures, surgeons need to be confident it does not result in a performance drop. In April 2016 medial unicompartmental knee arthroplasties (MUKAs) were implemented at our center. During this we monitored patient reported outcome measurements (PROMs).
Purpose / Aim of Study: The aim of this study was to compare patient reported outcomes following MUKA and compare them to TKAs with anteromedial osteoarthritis (AMOA) performed prior to implementation of MUKA.
Materials and Methods: The last 158 TKAs with AMOA on their pre-operative radiographs performed prior to introductions of MUKA were identified and compared to the first 172 MUKA procedures.. Oxford knee scores (OKS) and Forgotten joint scores (FJS) were collected preoperatively and at 3, 12 and 24 months follow-up (f/u). Patient demographics included gender, age, BMI, ASA and Kellgren-Lawrence grades.
Findings / Results: The time series analyses showed significant differences for all three PROMs in the favor of MUKA with p-value < 0.0001. Values presented are mean adjusted improvements from baseline values with CI 95 %. For FJS the MUKAs improved by 30.70 (26.72 - 34.67) at 3 months, 43.93 (39.28 - 48.59) at 1 year and 45.80 (39.84 - 51.76) at 2 years. TKAs improved by 30.91 (23.25 - 38.56) at 3 months, 37.74 (32.22 - 43.26) at 1 year and 39.89 (34.16 - 45.63) at 2 year (p-values: 1.40e-14– 4.13e-59). For OKS the MUKAs improved by 10.14 (8.86 - 11.42) at 3 months, 15.16 (13.73 - 16.59) at 1 year and 15.51 (13.74 - 17.27) at 2 years. TKAs improved by 9.07 (6.83 - 11.31) at 3 months, 14.32 (13.00 - 15.64) at 1 year and 15.01 (13.55 - 16.47) at 2 years (p-values: 9.57e-15 - 9.56e-73). 52 % of MUKAs and 42 % of TKAs reached an excellent outcome (OKS > 41) at 1 year.
Conclusions: Both procedures show an overall improvement. MUKAs showed significantly larger and more rapid improvements than TKAs. The TKAs approached the MUKAs scores at 2 years for OKS, but do not reach the same results for FJS. In conclusion the gain by using MUKA, when measured in knee specific PROMs, is achieved immediately after implementation and becomes clinically important when seen in the context of nationwide healthcare.
Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre
Background: When implementing new procedures, surgeons need to be confident it does not result in a performance drop. In April 2016 medial unicompartmental knee arthroplasties (MUKAs) were implemented at our center. During this we monitored patient reported outcome measurements (PROMs).
Purpose / Aim of Study: The aim of this study was to compare patient reported outcomes following MUKA and compare them to TKAs with anteromedial osteoarthritis (AMOA) performed prior to implementation of MUKA.
Materials and Methods: The last 158 TKAs with AMOA on their pre-operative radiographs performed prior to introductions of MUKA were identified and compared to the first 172 MUKA procedures.. Oxford knee scores (OKS) and Forgotten joint scores (FJS) were collected preoperatively and at 3, 12 and 24 months follow-up (f/u). Patient demographics included gender, age, BMI, ASA and Kellgren-Lawrence grades.
Findings / Results: The time series analyses showed significant differences for all three PROMs in the favor of MUKA with p-value < 0.0001. Values presented are mean adjusted improvements from baseline values with CI 95 %. For FJS the MUKAs improved by 30.70 (26.72 - 34.67) at 3 months, 43.93 (39.28 - 48.59) at 1 year and 45.80 (39.84 - 51.76) at 2 years. TKAs improved by 30.91 (23.25 - 38.56) at 3 months, 37.74 (32.22 - 43.26) at 1 year and 39.89 (34.16 - 45.63) at 2 year (p-values: 1.40e-14– 4.13e-59). For OKS the MUKAs improved by 10.14 (8.86 - 11.42) at 3 months, 15.16 (13.73 - 16.59) at 1 year and 15.51 (13.74 - 17.27) at 2 years. TKAs improved by 9.07 (6.83 - 11.31) at 3 months, 14.32 (13.00 - 15.64) at 1 year and 15.01 (13.55 - 16.47) at 2 years (p-values: 9.57e-15 - 9.56e-73). 52 % of MUKAs and 42 % of TKAs reached an excellent outcome (OKS > 41) at 1 year.
Conclusions: Both procedures show an overall improvement. MUKAs showed significantly larger and more rapid improvements than TKAs. The TKAs approached the MUKAs scores at 2 years for OKS, but do not reach the same results for FJS. In conclusion the gain by using MUKA, when measured in knee specific PROMs, is achieved immediately after implementation and becomes clinically important when seen in the context of nationwide healthcare.
Christian Emil Husted, Henrik Husted, Helle Krogshøj Hansen, Billy B Kristensen, Kirill Gromov
Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Ambulatory Surgery Department, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen
Background: Outpatient total joint arthroplasty in ambulatory surgery center vs standard patient ward – a randomized controlled trial Christian Emil Husted, Henrik Husted, Helle Krogshøj Hansen, Billy B Kristensen, Kirill Gromov Ortopædkirurgisk afdeling, Hvidovre Hospital Discharge on the day of surgery (DOS) among selected patients operated with total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been shown to be feasible and safe. However, different factors play a part in determining whether patients are discharged on the DOS or not and location may be one of them.
Purpose / Aim of Study: The purpose of this study was to investigate the importance of the setting in which the short stay following THA or TKA takes place: was there a significant difference between the proportion of patients being discharged on the DOS when staying at an ambulatory surgery center (ASC) compared to patients staying at a regular ward after surgery.
Materials and Methods: In total 154 patients (64 THA, 90 TKA) were screened for eligibility to undergo fast-track surgery in an outpatient setting. Of those, 50 patients (30 TKA, 20 THA) were all operated in the ASC by one experienced surgeon and immediately postoperatively randomized to either staying in the ASC or being transferred to the regular ward.
Findings / Results: Ninety-six % (n=24) of the patients who stayed at the ASC vs 80% (n=20) of the patients at the ward were discharged on the DOS following fulfillment of discharge criteria. All THA patients were discharged, but significant more TKA patients were discharged from the ASC (p=0.044) resulting in an overall nearly significant difference between the two groups of patients regarding discharge on the DOS (power all=0.082). There was no difference between patients staying at the ASC or the ward regarding gender (pTKA=0.431/pTHA=0.964), age (pTKA=0.136/pTHA=0.72), ASA-score (pTKA=0.232/pTHA=0.436), BMI (pTKA=0.51/pTHA=0.685), surgery time (pTKA=0.459/pTHA=0.138), or blood loss (pTKA=0.287/pTHA=0.999).
Conclusions: Despite fixed discharge criteria, the setting may play a role for achieving early discharge, which may be facilitated be the presence of a dedicated anesthetist reducing pain and dizziness.
Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen; Ambulatory Surgery Department, Copenhagen , University Hospital Hvidovre, Copenhagen; Department of Orthopedic Surgery, Copenhagen , University Hospital Hvidovre, Copenhagen
Background: Outpatient total joint arthroplasty in ambulatory surgery center vs standard patient ward – a randomized controlled trial Christian Emil Husted, Henrik Husted, Helle Krogshøj Hansen, Billy B Kristensen, Kirill Gromov Ortopædkirurgisk afdeling, Hvidovre Hospital Discharge on the day of surgery (DOS) among selected patients operated with total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been shown to be feasible and safe. However, different factors play a part in determining whether patients are discharged on the DOS or not and location may be one of them.
Purpose / Aim of Study: The purpose of this study was to investigate the importance of the setting in which the short stay following THA or TKA takes place: was there a significant difference between the proportion of patients being discharged on the DOS when staying at an ambulatory surgery center (ASC) compared to patients staying at a regular ward after surgery.
Materials and Methods: In total 154 patients (64 THA, 90 TKA) were screened for eligibility to undergo fast-track surgery in an outpatient setting. Of those, 50 patients (30 TKA, 20 THA) were all operated in the ASC by one experienced surgeon and immediately postoperatively randomized to either staying in the ASC or being transferred to the regular ward.
Findings / Results: Ninety-six % (n=24) of the patients who stayed at the ASC vs 80% (n=20) of the patients at the ward were discharged on the DOS following fulfillment of discharge criteria. All THA patients were discharged, but significant more TKA patients were discharged from the ASC (p=0.044) resulting in an overall nearly significant difference between the two groups of patients regarding discharge on the DOS (power all=0.082). There was no difference between patients staying at the ASC or the ward regarding gender (pTKA=0.431/pTHA=0.964), age (pTKA=0.136/pTHA=0.72), ASA-score (pTKA=0.232/pTHA=0.436), BMI (pTKA=0.51/pTHA=0.685), surgery time (pTKA=0.459/pTHA=0.138), or blood loss (pTKA=0.287/pTHA=0.999).
Conclusions: Despite fixed discharge criteria, the setting may play a role for achieving early discharge, which may be facilitated be the presence of a dedicated anesthetist reducing pain and dizziness.
Christian Bredgaard Jensen, Anders Troelsen, Christian Skovgaard Nielsen, Niels Kristian Stahl Otte, Henrik Husted, Kirill Gromov
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Discharge on the day of surgery (DOS) is reported to be safe and effective after unicompartmental knee arthroplasty (UKA). Previous studies have determined risk factors for prolonged length of stay, but little is known about specific factors resulting in continued hospitalization within the first postoperative days after UKA.
Purpose / Aim of Study: To investigate what clinical and logistical factors prevent patients from being discharged on the day of surgery and the first postoperative day following primary UKA in a fast track setting.
Materials and Methods: We prospectively collected data on 100 unselected UKA patients operated from December, 2017 to May, 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge. A form screening all discharge criteria was filled out before 8pm on DOS and postoperative day 1 and 2 if the patients were still in the hospital.
Findings / Results: Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and the first postoperative day respectively (27% and 80% respectively, when only considering patients operated as #1 and #2). Lack of mobilization only and pain only delayed discharge in respectively 78% and 24% of patients, respectively. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). Urinary retention, nausea or vomiting, circulatory insufficiency, and wound issues delayed discharge in fewer cases (2-11%). For patients operated as #1 and #2 we found that; If mobilization only was managed successfully, the discharge rate on DOS would increase to 55%. If pain only was managed successfully, the discharge rate on DOS would increase to 40%.
Conclusions: 22% of unselected UKA patients operated in a standardized fast-track setup are discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24-48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and the setup regarding postoperative mobilization.
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Discharge on the day of surgery (DOS) is reported to be safe and effective after unicompartmental knee arthroplasty (UKA). Previous studies have determined risk factors for prolonged length of stay, but little is known about specific factors resulting in continued hospitalization within the first postoperative days after UKA.
Purpose / Aim of Study: To investigate what clinical and logistical factors prevent patients from being discharged on the day of surgery and the first postoperative day following primary UKA in a fast track setting.
Materials and Methods: We prospectively collected data on 100 unselected UKA patients operated from December, 2017 to May, 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge. A form screening all discharge criteria was filled out before 8pm on DOS and postoperative day 1 and 2 if the patients were still in the hospital.
Findings / Results: Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and the first postoperative day respectively (27% and 80% respectively, when only considering patients operated as #1 and #2). Lack of mobilization only and pain only delayed discharge in respectively 78% and 24% of patients, respectively. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). Urinary retention, nausea or vomiting, circulatory insufficiency, and wound issues delayed discharge in fewer cases (2-11%). For patients operated as #1 and #2 we found that; If mobilization only was managed successfully, the discharge rate on DOS would increase to 55%. If pain only was managed successfully, the discharge rate on DOS would increase to 40%.
Conclusions: 22% of unselected UKA patients operated in a standardized fast-track setup are discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24-48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and the setup regarding postoperative mobilization.
Mette Mikkelsen, Hannah Wilson, Kirill Gromov, Andrew Price, Anders Troelsen
Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Nuffield Dept. of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Nuffield Dept. of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre
Background: The choice between total- and unicompartmental knee replacement (TKA/UKA) is a continued area of discussion. Internationally unicompartmental knee replacements are still lacking behind the total replacements even though it has fewer complications and readmissions, lower mortality and better functional outcomes. Liddle et al. showed a small but significant difference in favor of the unicompartmental arthroplasty in patient reported outcome measurements (PROMs) in 2014. We aimed to investigate this further, however using only the total knee replacements that would have been suitable for a medial unicompartmental replacement.
Purpose / Aim of Study: Thus the aim of this study was to investigate any difference in Oxford Knee Scores at 1 year between TKAs with anteromedial osteoarthritis (AMOA) and medial UKA (MUKA).
Materials and Methods: We did a dual center cohort study where all TKAs were recruited from a center that didn’t offer MUKA at the time, and all MUKAs were included from a center that does MUKA if it is possible. The TKAs’ pre-operative radiographs were evaluated to identify patients with AMOA. A total of 500 patients were included (301 MUKA) from 2013-2016. We investigated the change score for OKS from pre-operative to 1 year post- operative and the proportion of patients achieving the patient accepted symptom state (PASS) of > 31.56 OKS at 1 year follow-up. Patient demographics included gender and age in both analyses and additionally pre-operative OKS in the PASS analysis.
Findings / Results: The change score at 1 year showed a mean adjusted difference of 4.38 OKS (CI 95 % 2.84-5.92) in favor of the MUKAs (p-value of 4.07e-08). The proportion of MUKAs achieving PASS was 88.70 % compared to 81.91 % for TKAs with an OR of 2.59 and a p-value of 0.00104.
Conclusions: In conclusion we found a significant difference in change score between the two procedures similarly to previously published series. We found an OR of 2.59 in favor of MUKA for achieving PASS. Even with the limitations of this study, we are confident in the conclusion that there is a difference in change in OKS at 1 year between MUKA and TKA and that MUKA has a higher chance of achieving PASS.
Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Nuffield Dept. of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Nuffield Dept. of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford; Dept. of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre
Background: The choice between total- and unicompartmental knee replacement (TKA/UKA) is a continued area of discussion. Internationally unicompartmental knee replacements are still lacking behind the total replacements even though it has fewer complications and readmissions, lower mortality and better functional outcomes. Liddle et al. showed a small but significant difference in favor of the unicompartmental arthroplasty in patient reported outcome measurements (PROMs) in 2014. We aimed to investigate this further, however using only the total knee replacements that would have been suitable for a medial unicompartmental replacement.
Purpose / Aim of Study: Thus the aim of this study was to investigate any difference in Oxford Knee Scores at 1 year between TKAs with anteromedial osteoarthritis (AMOA) and medial UKA (MUKA).
Materials and Methods: We did a dual center cohort study where all TKAs were recruited from a center that didn’t offer MUKA at the time, and all MUKAs were included from a center that does MUKA if it is possible. The TKAs’ pre-operative radiographs were evaluated to identify patients with AMOA. A total of 500 patients were included (301 MUKA) from 2013-2016. We investigated the change score for OKS from pre-operative to 1 year post- operative and the proportion of patients achieving the patient accepted symptom state (PASS) of > 31.56 OKS at 1 year follow-up. Patient demographics included gender and age in both analyses and additionally pre-operative OKS in the PASS analysis.
Findings / Results: The change score at 1 year showed a mean adjusted difference of 4.38 OKS (CI 95 % 2.84-5.92) in favor of the MUKAs (p-value of 4.07e-08). The proportion of MUKAs achieving PASS was 88.70 % compared to 81.91 % for TKAs with an OR of 2.59 and a p-value of 0.00104.
Conclusions: In conclusion we found a significant difference in change score between the two procedures similarly to previously published series. We found an OR of 2.59 in favor of MUKA for achieving PASS. Even with the limitations of this study, we are confident in the conclusion that there is a difference in change in OKS at 1 year between MUKA and TKA and that MUKA has a higher chance of achieving PASS.