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Background: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level.Methods: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts.Results: Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list.Conclusions: Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures.Level Of Evidence: Level III Retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.Methods: From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was 'days alive and at home up to 30 days after surgery' (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.Results: Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3-5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25-27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).Conclusion: Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if 'buy-in' from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.Trial Registration: The study was registered with ClinicalTrials.gov ( NCT03540667 ). [ABSTRACT FROM AUTHOR]