Introduction: In recent years, day-case hip and knee arthroplasty has emerged as a potential solution to the elective backlog within the NHS. While international literature on this topic is extensive, only a handful of single-centre studies have been conducted in the United Kingdom. This study aimed to examine the safety and efficacy of day-case hip and knee arthroplasty in the UK using a 20-year linked national NHS dataset.
Methods: A cohort study was conducted using the Clinical Practice Research Datalink (CPRD), linked to Hospital Episode Statistics (HES) and the Office for National Statistics death registry. Adults undergoing primary hip or knee arthroplasty between 1998 and 2021 were included. Procedures were classified as day-case or inpatient, using two distinct approaches: patient classification and length of stay. Day-case is defined as discharge on the same day of the procedure, while inpatient procedures involve undergo at least one overnight stay in hospital. The primary outcomes assessed were A&E attendance, readmission, and critical care admission within 90-days post-operatively. Secondary outcomes included 90-day complication rates and survival analysis. Propensity score matching was implemented to adjust outcomes for age, gender, comorbidity burden, deprivation index, and ethnicity.
Results: In total, 1,822 (0.16%) procedures were classified as day-case, while 4,355 (0.37%) had a recorded length of stay of 0 days. On average, patients undergoing day-case arthroplasty were younger, more often male, and had fewer comorbidities than their inpatient counterparts. Higher rates of A&E attendance (12% vs 9.1%; P = 0.001) and readmission (5.7% vs 3.7%; P < 0.001) were observed in the day-case cohort. In contrast, deep vein thrombosis (0.5% vs 0.9%; P = 0.010) and infection rates (1.0% vs 1.9%; P = 0.014) were lower in this patient group. Survival analyses demonstrated significantly higher adjusted survival probabilities associated with day-case arthroplasty (HR: 0.84; [95% CI: 0.72-0.99]; P = 0.034) over a 20-year follow-up period.
Conclusion: Day-case hip and knee arthroplasty has been demonstrated to be safe and feasible, with comparable complication rates to the traditional inpatient setting. However, within the context of the NHS, it is currently associated with higher rates of 90-day A&E attendance and readmission. While increasing day-case volumes may help address elective backlogs, it is important to ensure that the appropriate patient selection criteria, optimised peri-operative care, and post-discharge support are in place before this approach is expanded in the UK.
Objective: To introduce a medial femoral condyle restoration (MFCR) technique for total knee arthroplasty (TKA) and compare its clinical outcomes with conventional mechanical alignment (MA) in varus osteoarthritis.
Methods: In this prospective randomized trial, 126 consecutive patients with varus osteoarthritis undergoing TKA (January 2021-January 2023) were assigned to MFCR or MA. MFCR surgical key points were medially focused quantitative compensation of cartilage loss by reducing distal/posterior medial femoral resections using thickness-specific shims (0.5-2.0 mm, 0.5-mm steps) guided by Outerbridge grading and calibrated probing. Participants were randomized to receive either the MFCR technique or the conventional MA technique. Intraoperative outcomes (blood loss, operative time, hospital stay, and medial release) and postoperative ROM were recorded; functional outcomes included WOMAC and walking VAS pain. Continuous variables were expressed as mean ± standard deviation and analyzed using one-way analysis of variance.
Results: The mean age of the MFCR group and control group was 68.3 ± 7.4 years and 67.9 ± 8.7 years, respectively (P = 0.4236). Preoperatively, the mean WOMAC score of the groups was 67.2 ± 9.8 and 62.3 ± 16.4, respectively (P = 0.2524). The mean varus knee angle was 18.2° ± 7.2° and 17.3° ± 8.9°, respectively (P = 0.6735). The mean time for soft tissue balancing was 5.1 ± 2.6 min and 12.1 ± 4.3 min in the MFCR and control group, respectively (P = 0.017). The mean operative time was 50.6 ± 12.1 min and 58.9 ± 13.8 min in the MFCR and control group, respectively (P = 0.011). The mean hospital stay time was 1.8 ± 0.7 days and 3.2 ± 0.9 days in the MFCR and control group, respectively (P = 0.028). At 2 years postoperatively, the WOMAC scores were 29.9 ± 17.9 and 43.6 ± 13.7, respectively (P = 0.0325). Postoperative nausea/vomiting occurred less frequently in the MFCR group (P = 0.0391), with no other complications observed during follow-up.
Conclusion: MFCR restored the anatomy of the medial femoral condyle by quantitatively preserving medial femoral bone to compensate for cartilage loss within a bony-first, minimal-release workflow. Compared with MA, MFCR reduced perioperative burden and improved early function, and can be implemented using a simple, reproducible technique without advanced imaging or robotics. Video Abstract.
Background: While frailty assessment has become integral to preoperative risk stratification, the optimal measurement tool remains unclear for elderly women undergoing total shoulder arthroplasty (TSA). This study compared the predictive performance of the Risk Analysis Index (RAI) against traditional metrics, including the modified frailty index-5 (mFI-5) and Geriatric Nutritional Risk Index (GNRI) in this specific population.
Methods: We conducted a retrospective analysis of ACS NSQIP data from 2015-2021, including female patients aged 65-89 undergoing inpatient TSA. RAI incorporates age, functional status, recent weight loss, and physiological markers, including renal failure, congestive heart failure, and dyspnea. The mFI-5 assesses five comorbidities (diabetes, hypertension, COPD, heart failure, functional dependence), while the GNRI evaluates nutritional status using albumin and body weight. The discriminative ability of RAI, mFI-5, and GNRI was assessed using area under the curve (AUC) analysis for multiple 30-day outcomes. Primary outcomes were non-home discharge and extended length of stay (≥ 4 days), selected based on their clinical importance for discharge planning and quality metrics. Secondary outcomes included 30-day mortality, major and minor complications, readmission, and reoperation. Discriminative ability was assessed using area under the curve (AUC) analysis. Internal validation was performed using bootstrap resampling.
Results: Among 11,965 patients analyzed, RAI demonstrated superior predictive performance for primary outcomes with AUCs of 0.784 for non-home discharge and 0.670 for extended length of stay, significantly outperforming mFI-5 (AUCs 0.601 and 0.590, respectively) and GNRI (AUCs 0.544 and 0.543). For secondary outcomes, RAI maintained competitive performance across mortality, complications, readmissions, and reoperations.
Conclusion: The Risk Analysis Index provides superior discrimination for non-home discharge and extended length of stay compared to traditional frailty measures in elderly female TSA patients, with particularly strong predictive performance for discharge disposition, supporting its adoption as the preferred risk stratification tool for discharge planning in this population. Video Abstract.
Aims: Inaccurate femoral neck osteotomy is a recognized technical challenge in direct anterior approach total hip arthroplasty (DAA-THA), largely due to limited femoral exposure and the absence of a standardized intraoperative landmark. This study aimed to investigate whether the ITL is an alternative bony landmark for femoral neck osteotomy during the DAA.
Patients and methods: Three anatomical references, the Intertrochanteric line (ITL) height (ITL-H), ITL angle (ITL-A), and femoral saddle height (SH), were measured from 3D-CT models of 60 normal hip patients (30 males and 30 females) to simulate a cutting height of 10 mm above the LT. Twenty cadaveric hip specimens were then used to evaluate the accuracy of the proposed anatomical references.
Results: The mean ITL-H, ITL-A, and SH were 23 ± 4 mm, 17.4° ± 3.5°, and 26 ± 4 mm, respectively. While ITL-H showed no sex difference (23 ± 3.4 mm vs 23.1 ± 4.1 mm, P = 0.96), significant differences existed for ITL-A (15.8° ± 3.4° vs 19.9° ± 1.4°, P = 0.001) and SH (27.2 ± 3.9 mm vs 23.9 ± 3 mm, P = 0.002). ITL-H was not correlated with age (P = 0.063), femoral length (P = 0.31), or femoral neck shaft angle (P = 0.41). Femoral neck osteotomy performed 23 mm above the ITL-H could yield 80% and 100% success rates for cutting heights of 10-15 mm and > 5 mm above the LT, respectively.
Conclusions: ITL-H serves as a reproducible anatomical landmark for femoral neck osteotomy during DAA-THA. An osteotomy level of approximately 23 mm above the ITL-H represents a safe lower margin to avoid excessive calcar bone resection. Nevertheless, individualized preliminary osteotomy based on preoperative templating remains necessary, with intraoperative adjustment according to patient-specific ITL-H. Video Abstract.
Background: Rates of total knee arthroplasty (TKA) in the United States have risen in patients of a wide age range. Although rates of postoperative TKA complications have decreased, they remain a significant concern. In this study, we aim to determine how the risk of adverse TKA outcomes changes dynamically with age and explore the optimal ages with the lowest risk for adverse outcomes.
Methods: This retrospective cohort study included patients who underwent elective primary TKA from 2012 to 2018 in the Pennsylvania Health Care Cost Containment Council Database. We trained (70% train:30% test) an explainable boosting machine (EBM), a modern generalized additive model, to predict risk for 90-day mortality, 90-day readmission, 1-year revision, and longer length of stay (LOS). This "glass box" model allowed us to measure and visualize feature importance using mean absolute scores and determine the role of age in the model. We then ran EBM models that allowed two-way interactions between age and patient-level covariates.
Results: In our cohort of 227,959 patients, 90-day readmission was observed in 7.5%, 90-day mortality in 0.2%, and 1-year revision in 0.8%. The median LOS was 2 days (IQR [2, 3]). Age was among the most important factors for predicting all outcomes, and these were nonlinear relationships. The risk for 90-day mortality increased substantially at 76.5 years, and for 90-day readmission and longer LOS at 73.5 years. Risk for 1-year revision was greater before 63.5 years.
Conclusions: We determined that there is a nonlinear relationship between age and risk for adverse TKA outcomes, and it changes dramatically at specific time points. Our data suggests that the optimal age for lower risk of 90-day mortality, 90-day readmission, and longer LOS is below 73.5 years, and above 63.5 years for 1-year revision. These findings can help in decision-making when trying to quantify risks related to aging.
Purpose: To compare 90-day readmissions, complications, and resource use after robotic-assisted versus conventional total knee arthroplasty (TKA) in a contemporary, nationally representative cohort.
Methods: Retrospective cohort study using the Nationwide Readmissions Database (NRD) 2020-2022. Primary TKA identified from the PR1 field (ICD-10-PCS). Exclusions included non-elective admissions, revisions, bilateral procedures, age < 18, oncology/fracture/reoperation, COVID-19, and discharges after September. Readmissions within 90 days were categorized (prosthesis/SSI, mechanical/implant, VTE). 1:1 propensity score matching (nearest neighbor, caliper 0.01, no replacement) included demographics, comorbidities, hospital factors, and year.
Results: After matching, 96,982 patients (48,491 per group) were analyzed. Robotic TKA showed lower all-cause 90-day readmission (5.0% vs 6.5%), superior readmission-free survival (log-rank P < 0.001), shorter readmission LOS (4.8 vs 5.6 days), and lower readmission charges ($66,769 vs $75,544), with slightly higher index charges ($78,125 vs $74,090). Risks were lower for VTE/PE, pneumonia, transfusion, postoperative pain, and prosthesis/SSI-related and mechanical readmissions.
Conclusions: In the largest contemporary national analysis, robotic TKA was associated with fewer early complications, lower 90-day readmissions, and reduced readmission resource use compared with conventional TKA.
Background: An augmented reality (AR)-aided navigation system that utilizes a standard smartphone enables accurate alignment of femoral and tibial components in total knee arthroplasty (TKA) and provides real-time intraoperative quantification of joint gaps. This study aimed to integrate the AR-aided navigation system into the surgical technique of restricted kinematic alignment and to evaluate its clinical effectiveness.
Methods: We compared 45 restricted kinematic alignment TKAs performed using posterior cruciate ligament (PCL) retaining medial-congruent prosthesis with an AR-aided navigation system and 40 mechanically aligned TKAs performed using PCL resecting posterior-stabilized prosthesis in patients with preoperative varus or neutral lower limb alignment. In the restricted kinematic alignment group, femoral and tibial alignments were determined using calipered and soft tissue-guided techniques, respectively, with the AR-aided navigation system providing real-time confirmation that angular values remained within safe boundaries. The target intraoperative extension gap was a rectangular configuration with equal medial and lateral widths.
Results: Intraoperative measured value of the soft-tissue imbalance with the knee in extension was significantly smaller in the restricted kinematic alignment group than in the mechanical alignment group (1.1 ± 1.1° vs 2.5 ± 2.2°; 95% CI, 0.7 to 2.2°; P < 0.001; Cohen's d = 0.85). After propensity score matching, no significant differences were observed between the groups in either the timed up-and-go test or the 10-m walk test at 1 week postoperatively (12.6 ± 3.5 s vs 13.2 ± 5.3 s; 95% CI, - 3.0 to 1.7; P = 0.60; and 11.7 ± 2.5 s vs 11.9 ± 3.2 s; 95% CI, - 1.7 to 1.3; P = 0.82, respectively).
Conclusions: Restricted kinematic alignment TKA using PCL retaining medial-congruent prosthesis achieved more balanced intraoperative soft-tissue tension than the mechanical alignment TKA using posterior-stabilized prosthesis. However, early postoperative walking speed did not differ between the two groups.
Background: For robotic-assisted total knee arthroplasty (TKA), accurate identification of anatomical landmarks directly affects the displayed value for femoral component rotation. This study aimed to quantify the inter-surgeon consistency of the TEA-reference angle (the angle between the transepicondylar axis and the femoral component axis) and the PCA-reference angle (the angle between the posterior condylar axis and the femoral component axis).
Methods: The anatomical data of 56 patients who underwent robotic-assisted TKA at our institution were analyzed. Two surgeons independently identified the transepicondylar axis (TEA) and posterior condylar axis (PCA) landmarks on the 3D femoral models generated by the MAKO TKA system. The TEA-reference angle was recorded as α with the PCA-reference angle standardized to 0°, and the PCA-reference angle was recorded as β with the TEA-reference angle standardized to 0°. The measured values were α1β1 for Surgeon-1 and α2β2 for Surgeon-2. The differences between surgeons for α (∆α = α₁ - α₂) and β (∆β = β₁ - β₂) were calculated. The values of α and β are defined as positive for external rotation and negative for internal rotation.
Results: The inter-surgeon intraclass correlation coefficient (ICC) for α was 0.761 (95% CI: 0.592-0.860), and that for β was 0.943 (95% CI: 0.902-0.966). The absolute difference between surgeons (∆α) was > 2° in 15/56 (26.8%) patients and ≤ 1° in 24/56 (42.9%) patients. With respect to ∆β, 3/56 (5.4%) patients had a difference > 2°, whereas 45/56 (80.4%) patients had a difference ≤ 1°.
Conclusion: The inter-surgeon consistency of the PCA was significantly greater than that of the TEA in robotic-assisted TKA planning. To mitigate the risk of inappropriate femoral component rotation, surgeons should verify landmark positions, particularly in patients with anatomical abnormalities of the distal femur, and consider cross-referencing both axes. Video Abstract.
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：