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Background: Hip dislocation is one of the most common postoperative complications after total hip arthroplasty (THA). Potential contributors include patient- and surgical-related factors. We performed a retrospective cohort study to identify risk factors for postoperative dislocation in patients receiving THA via the posterolateral approach.Methods: We assessed 1326 consecutive primary THAs performed between 2010 and 2015. Patient information was documented, and plain radiographic films were used to evaluate cup positioning, hip offset, and hip length change. A multiple logistic regression was used to identify risk factors for dislocation. Follow-up was coordinated by the Danish National Patient Registry.Results: Age and American Society of Anesthesiologists scores were higher in dislocating THA compared with those in the nondislocating THA. Cup anteversion was less in dislocating THA compared with that in nondislocating THA. Independent risk factors for cup dislocation were increased age, body mass index <25 and >30 kg/m2, and leg shortening of >5 mm.Conclusion: Surgeons should aim for a shortening of leg length <5 mm to reduce the risk of postoperative dislocation in primary THA. Although anteversion was reduced for dislocating THA, there is likely no universal safe zone for cup positioning. Hip stability is multifactorial, and optimal cup positioning may vary from patient to patient. [ABSTRACT FROM AUTHOR]

Background: Fast-track total hip and knee arthroplasty (THA and TKA) has been shown to reduce the perioperative convalescence resulting in less postoperative morbidity, earlier fulfillment of functional milestones, and shorter hospital stay. As organizational optimization is also part of the fast-track methodology, the result could be a more cost-effective pathway altogether. As THA and TKA are potentially costly procedures and the numbers are increasing in an economical limited environment, the aim of this study is to present baseline detailed economical calculations of fast-track THA and TKA and compare this between 2 departments with different logistical set-ups.Methods: Prospective data collection was analyzed using the time-driven activity-based costing method (TDABC) on time consumed by different staff members involved in patient treatment in the perioperative period of fast-track THA and TKA in 2 Danish orthopedic departments with standardized fast-track settings, but different logistical set-ups.Results: Length of stay was median 2 days in both departments. TDABC revealed minor differences in the perioperative settings between departments, but the total cost excluding the prosthesis was similar at USD 2511 and USD 2551, respectively.Conclusion: Fast-track THA and TKA results in similar cost despite differences in the organizational set-up. Compared to cost associated with longer more conventional published pathways, fast-track is cheaper, which on top of the favorable published clinical outcome adds to cost efficiency and the potential for economic savings. Detailed baseline TDABC calculations are provided for comparison and further optimization of cost-benefit effectiveness. [ABSTRACT FROM AUTHOR]

Background: Postoperative anemia is frequent after revision of total knee arthroplasty (TKA) with reported transfusion rates up to 83%. Despite increased efforts of reducing blood loss and enhancing fast recovery within the fast-track setup, a considerable transfusion rate is still evident. The aim of this study was therefore to evaluate the effect of a bipolar sealer on blood loss and transfusion in revision TKA.Methods: In this single-center prospective cohort study with retrospective controls, 51 patients were enrolled in a fast-track setup for revision TKA without the use of a tourniquet. Twenty-five prospectively enrolled patients received treatment with both a bipolar sealer and electrocautery, whereas 26 patients had received treatment with a conventional electrocautery only in the retrospective group.Results: No significant differences were found neither for calculated blood loss, with 1397 (standard deviation, ± 452) mL in the bipolar sealer group vs 1452 (SD, ± 530) mL in the control group (P = .66), nor for blood transfusion rates of 53% and 46% (P = .89), respectively. Four controls were readmitted within 90 days follow-up.Conclusion: The use of a bipolar sealer in a TKA revision setting without the use of a tourniquet did not reduce blood loss or blood transfusion rates. [ABSTRACT FROM AUTHOR]

In this study, we examined the association between obesity and patient-reported outcome measures after medial unicompartmental knee arthroplasty (MUKA), assessed through score changes, Patient Acceptable Symptom State (PASS), and minimal important change (MIC). Second, the association between obesity and early readmissions was examined. A total of 450 MUKAs (mean body mass index [BMI] 30.3, range, 19.6-53.1), performed from February 2016 to December 2020, were grouped using BMI: <30, 30-34.9, and >34.9. Oxford Knee Score (OKS), Forgotten Joint Score (FJS), and Activity and Participation Questionnaire (APQ) were assessed preoperatively and at 3, 12, and 24 months, postoperatively. The 12-month PASS and MIC were also assessed, defining PASS as OKS = 30, MIC-OKS as change in OKS = 8, and MIC-FJS as change in FJS = 14. No significant differences in OKS change were found between BMI groups. After 12 months, patients who had a BMI of 30-34.9 had lower change in FJS (estimate −8.1, 95% CI −14.9 to −1.4) and were less likely to reach PASS (odds ratio 0.4, 95% CI 0.2-0.7) as well as MIC-FJS (odds ratio 0.5, 95% CI 0.2-0.9). Both obese groups had lower change in APQ after 12 months. Differences in 90-day readmission rates were nonsignificant between groups. Our findings of no differences in OKS improvement between BMI groups and achieving MIC for BMI > 34.9 suggest good improvements in obese patients despite lower preoperative scores, supporting contemporary indications for MUKA. Lower APQ development and achievement of 12-month PASS may be used when addressing expectations of recovery. [ABSTRACT FROM AUTHOR]

Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking. A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg−1 vs 0.3 mg kg−1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90. A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8–1.4, P =0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6–25] mg L−1 vs 16 [9–38] mg L−1, P = 0.07), but lower at 48 h (26 [9–52] mg L−1 vs 50 [30–72] mg L−1, P <0.01) in the high-dose group. Use of 1 mg kg−1 vs 0.3 mg kg−1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population. NCT03758170 (first registration 29-11-2018). [ABSTRACT FROM AUTHOR]

Purpose Methods Results Conclusion Level of Evidence To investigate the impact of orthopaedic surgeons' arthroplasty distributions on patient‐reported outcome measures (PROMs) following knee arthroplasty, thus addressing the gap in knowledge regarding the optimal distribution of arthroplasties.2256 knee arthroplasties were included (total knee arthroplasty [TKA] or unicompartmental knee arthroplasty [UKA]). All were conducted at a single centre between August 2016 and August 2022 with a minimum of 1‐year follow‐up. The Oxford Knee Score (OKS), the Forgotten Joint Score (FJS) and the Activity and Participation Questionnaire (APQ) were assessed preoperatively, and at 3 and 12 months postoperatively. Patients were categorized based on the surgeons' yearly surgeries: (1) TKA only, (2) TKA+ <20% medial UKA, (3) TKA+ ≥20% medial UKA and (4) TKA+ ≥20% medial UKA + lateral UKA + patellofemoral UKA. Linear regression models adjusted for demographic variables and preoperative PROM scores were used to estimate changes in mean PROM scores.Group 4 showed significantly higher improvements in PROM scores at 3 and 12 months compared to Group 1. In the 12‐month adjusted analysis, Group 4 had 1.9 points (95% confidence interval [CI]: 1.0–2.8) higher OKS‐, 7.0 points (95% CI: 3.9–10.2) higher FJS‐ and 8.3 points (95% CI: 4.8–11.8) higher APQ‐change than Group 1. There were no significant differences between Groups 1 and 2, nor any clinically relevant differences between Groups 3 and 4. Additionally, the percentage of patients who achieved excellent OKS (>41) was significantly higher in Groups 3 + 4 compared to Groups 1 + 2 (p < 0.001).Despite limitations, the findings of this study suggest that utilizing ≥20% medial UKA leads to greater postoperative improvements in PROM across all treated knee arthroplasty patients.Level III. [ABSTRACT FROM AUTHOR]

Background: Total knee arthroplasty is associated with an inflammatory response and high levels of pain in a subset of patients. Pain catastrophizing has been associated with acute postoperative pain. The association between these variables has not been investigated in an optimised fast‐track setup including preoperative glucocorticoids. The aim of this study was, first, to investigate the correlation between the increase in postoperative c‐reactive protein (CRP) and acute postoperative pain after total knee arthroplasty, and second, to investigate the correlation between the increase in CRP and preoperative pain catastrophizing. Methods: This study is a secondary analysis of data from 119 patients participating in two randomised controlled trials. Correlation analyses were performed for preoperative CRP and CRP increase at 24 and 48 h and pain during a well‐defined mobilisation at 24 and 48 h after total knee arthroplasty. Additionally, correlation analyses were performed between CRP increase and pain catastrophizing using the pain catastrophizing scale. Results: There was no correlation between preoperative CRP or postoperative CRP increase and pain at both 24 and 48 h. Analyses were similar when separated into high and low pain catastrophizers. There was no correlation between preoperative CRP or postoperative CRP increase and pain catastrophizing. Conclusion: There was no association between the postoperative CRP response and postoperative acute pain or pain catastrophizing in patients undergoing total knee arthroplasty in a well‐defined multimodal fast‐track regime including preoperative glucocorticoids. These results suggest that acute pain after knee arthroplasty is not reflected by CRP when applying preoperative glucocorticoids. [ABSTRACT FROM AUTHOR]

Psychopharmacological treatment may be an independent risk factor for increased length of stay and readmission after hip and knee replacement. Thus, temporary perioperative discontinuation may be beneficial. However, little is known regarding the treatments, and not all are feasible to discontinue. Therefore, the aim of this study was to describe the treatments in terms of type, dose, duration, indication and initiating physician to assess the feasibility of temporary perioperative discontinuation. We included 482 patients planned for hip or knee replacement in psychopharmacological treatment for psychiatric disorders from 2021 to 2023 at five orthopaedic departments in Denmark. Most patients were treated with antidepressants (89%); most frequently, either selective serotonin reuptake inhibitors (SSRIs; 48%) or serotonin‐norepinephrine reuptake inhibitors (SNRIs; 21%). The majority received monotherapy (70%); most frequently, an SSRI (36%) or an SNRI (12%). Most antidepressants were initiated by general practitioners (71%), and the treatments had lasted for more than a year (87%). The doses of SSRIs/SNRIs were moderate, and the most frequent indication for antidepressants was depression (77%). These results imply that temporary perioperative SSRI/SNRI discontinuation may be feasible in hip and knee replacement patients and support a future randomized controlled trial investigating the potential benefits of temporary discontinuation. [ABSTRACT FROM AUTHOR]

Background and purpose: Preoperative anaemia including iron deficiency anaemia (IDA) is a well-established perioperative risk factor. However, most studies on iron therapy to treat IDA have been negative and few have been conducted within an enhanced recovery after surgery (ERAS) protocol. Furthermore, patients with IDA often have comorbidities not necessarily influenced by iron, but potentially influencing traditional study endpoints such as length of stay (LOS), morbidity, etc. The aim of this paper is to discuss patient-related challenges when planning outcome studies on the potential benefits of iron therapy in patients with IDA, based upon a large detailed prospective database in ERAS total hip (THA) and knee arthroplasty (TKA). Methods: A prospective observational cohort study in ERAS THA and TKA from 2022 to 2023. Detailed complete follow-up through questionnaires and electronic medical records. Results: Of 3655 included patients, 276 (7.6%) had IDA defined as a haemoglobin (Hb) of < 13.0 g/dL and transferrin saturation of 0.20, while 3379 had a Hb of ≥ 13.0. Patients with IDA were a median 5 years older than non-anaemics, with an increased fraction living alone (38.4% vs. 28.8%), using walking aids (54.3% vs 26.4%) and receiving home care (16.2% vs 4.7%). Fewer IDA patients were working (12.7% vs. 29.6%) and a median number of prescribed drugs was higher (10 vs. 6). Median LOS was 1 day in both IDA and non-anaemic patients, but a LOS of > 2 days occurred in 11.6% of patients with IDA vs. 4.3% in non-anaemics. The proportion with 30- or 90-day readmissions was 6.5% vs. 4.1% and. 13.4% vs6.0%, in patients with IDA and non-anaemics, respectively. However, potentially anaemia or iron deficiency-related causes of LOS > 2 days or 90-day readmissions were only 5.4% and 2.2% in patients with IDA and 1.9% and 1.0% in non-anaemics. Conclusion: Conventional randomised trials with single or composite "hard" endpoints are at risk of being inconclusive or underpowered due to a considerable burden of other patient-related risk factors and with postoperative complications which may not be modifiable by correction of IDA per se. We will propose to gain further insights from detailed observational and mechanistic studies prior to initiating extensive randomised studies. [ABSTRACT FROM AUTHOR]

Background and purpose -- Despite increased attention to and acceptance of fast-track procedures, there is a lack of studies concerning discharge on the day of surgery (DOS) following total knee arthroplasty (SD-TKA). We evaluated the feasibility of SD-TKA, and compared safety and patientreported outcomes (PROs) between patients undergoing SD-TKA and patients undergoing standard TKA. Patients and methods -- A SD-TKA group (n = 101) was matched 1:1 to a standard TKA group (n = 101) on age, sex, and ASA score. Feasibility (being discharged on DOS), safety (unplanned contacts and complications evaluated by telephone calls (2 weeks), outpatient visits (2 weeks), and readmission (90 days)) were assessed. Further, Oxford Knee Score (OKS) and Visual Analogue Scale (VAS) (pain at rest and activity) were reported (90 days). Results -- 89 of 101 SD-TKA patients were discharged on DOS. The number of telephone calls (≤ 83) and outpatient visits (12) were similar in the 2 groups. The number of readmissions was ≤ 3 in both groups, and only 1 of the readmissions was related to TKA surgery. No differences were found at 90-day follow-up in terms of OKS (34 in both groups) or VAS (rest: SD-TKA = 7 and standard TKA = 8; activity: SD-TKA = 17 and standard TKA = 15). Interpretation -- SD-TKA is feasible in a selected group of patients, and safety and PROs are comparable to patients undergoing standard TKA. [ABSTRACT FROM AUTHOR]

Background: Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking.Methods: A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg-1 or intermediate-dose dexamethasone 0.3 mg kg-1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications.Results: Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01).Conclusions: When compared with preoperative dexamethasone 0.3 mg kg-1 i.v., dexamethasone 1 mg kg-1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects.Clinical Trial Registration: NCT03763734. [ABSTRACT FROM AUTHOR]

A letter to the editor and a reply are presented in response to the article "Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation," by Kirill Gromov and colleagues in the March 9, 2015 issue.

Introduction: Unicompartmental knee arthroplasty (UKA) is a well-accepted treatment for isolated unicompartmental osteoarthritis (OA) of the knee. In previous literature, it has been suggested that bi-unicompartmental knee arthroplasty (bi-UKA) which uses two UKA implants in both the medial and lateral compartments of the same knee is a feasible and viable option for the treatment of knee OA. Given the advantages of UKA treatment, it is warranted to review the literature of bi-UKA and discuss the evidence in terms of implant selection, indications, surgical techniques, and outcomes, respectively. Materials and methods: Following the PRISMA guidelines, PubMed, Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched for studies presenting outcome of bi-UKA. Studies were included if they reported clinical outcomes using two unicompartmental prostheses for both medial and lateral femorotibial arthritis. Studies with the addition of patellofemoral arthroplasty or concomitant soft-tissue reconstruction and those not published in English were excluded. Results: In the early literature, the procedure of bi-UKA were performed for very severe OA and rheumatoid arthritis, but indications have evolved to reflect a more contemporary case-mix of knee OA patients. Both mobile and fixed bearing implants have been used, with the latter being the most frequent choice. A medial parapatellar approach for incision and arthrotomy has been the most frequently used technique. The present review found a promising clinical outcome of both simultaneous and staged bi-UKA although the number of long-term follow-up studies was limited. Conclusions: Both simultaneous and staged bi-UKA has demonstrated good functional outcomes. However, the volume and level of evidence in general is low for studies captured in this review, and the data on long-term outcomes remain limited. The present review indicates that bi-UKA is a feasible and viable surgical option for bicompartmental femorotibial OA in carefully selected patients. [ABSTRACT FROM AUTHOR]

The osteoarthritic (OA) disease pattern of the knee is one of the determinants for choice of arthroplasty concept when knee replacement is indicated, but whether the disease pattern has a direct effect on postoperative outcome has not previously been investigated. The aim was to investigate if different OA disease patterns have an effect on postoperative outcome after receiving total knee arthroplasty (TKA).Materials and Methods: 472 patients with pre- and 1-year postoperative patient reported outcome measures (PROMs) undergoing TKA surgery were retrospectively identified and classification of the OA disease pattern was made on preoperative radiographs. Measured resection was the universal technical approach.Results: The key findings showed greater improvement in mean PROMs for anteromedial OA (AMOA) compared with other OA disease patterns; 3.1 points (95% CI 1.4-4.7, p < 0.001) in Oxford Knee score, 11.7 points (95% CI 0.9-22.5, p = 0.034) in Forgotten Joint score and 0.08 points (95% CI 0.02-0.14, p = 0.007) in EQ 5D score. Similar results were observed when comparing AMOA with AMOA that had only partial thickness cartilage loss (AMOA-PTCL).Conclusions: Patients with AMOA achieve greater improvement in PROMs after TKA surgery when using measured resection compared with other OA disease patterns. This finding has important implications for reporting, risk stratification and interpretation in TKA outcome studies, including randomized trials, why further investigation of the topic is of highly relevance. [ABSTRACT FROM AUTHOR]

Background: Machine-learning models may improve prediction of length of stay (LOS) and morbidity after surgery. However, few studies include fast-track programs, and most rely on administrative coding with limited follow-up and information on perioperative care. This study investigates potential benefits of a machine-learning model for prediction of postoperative morbidity in fast-track total hip (THA) and knee arthroplasty (TKA). Methods: Cohort study in consecutive unselected primary THA/TKA between 2014–2017 from seven Danish centers with established fast-track protocols. Preoperative comorbidity and prescribed medication were recorded prospectively and information on length of stay and readmissions was obtained through the Danish National Patient Registry and medical records. We used a machine-learning model (Boosted Decision Trees) based on boosted decision trees with 33 preoperative variables for predicting "medical" morbidity leading to LOS > 4 days or 90-days readmissions and compared to a logistical regression model based on the same variables. We also evaluated two parsimonious models, using the ten most important variables in the full machine-learning and logistic regression models. Data collected between 2014–2016 (n:18,013) was used for model training and data from 2017 (n:3913) was used for testing. Model performances were analyzed using precision, area under receiver operating (AUROC) and precision recall curves (AUPRC), as well as the Mathews Correlation Coefficient. Variable importance was analyzed using Shapley Additive Explanations values. Results: Using a threshold of 20% "risk-patients" (n:782), precision, AUROC and AUPRC were 13.6%, 76.3% and 15.5% vs. 12.4%, 74.7% and 15.6% for the machine-learning and logistic regression model, respectively. The parsimonious machine-learning model performed better than the full logistic regression model. Of the top ten variables, eight were shared between the machine-learning and logistic regression models, but with a considerable age-related variation in importance of specific types of medication. Conclusion: A machine-learning model using preoperative characteristics and prescriptions slightly improved identification of patients in high-risk of "medical" complications after fast-track THA and TKA compared to a logistic regression model. Such algorithms could help find a manageable population of patients who may benefit most from intensified perioperative care. [ABSTRACT FROM AUTHOR]

Introduction: Gastrointestinal complications after total hip (THA) and knee arthroplasty (TKA) have been reported to be between 0.3 and 2.6% with bleeding and C. difficile infection in 0–1%, and 0.1–1.7%, respectively. The use of enhanced recovery or "fast-track" protocols have focused on optimizing all aspects of perioperative care resulting in reduced length of hospital stay (LOS) and potentially also gastrointestinal complications. This study is a detailed analysis on the occurrence of postoperative gastrointestinal complications resulting in increased hospital stay or readmissions in a large consecutive cohort of fast-track THA and TKA with complete 90 days follow-up. Materials and methods: This is an observational study on a consecutive cohort of primary unilateral THAs and TKAs performed between January 2010 and August 2017 in nine Danish high-volume fast-track centers. Discharge summaries and relevant patient records were reviewed in patients with readmissions within 90 days or LOS > 4 days caused by gastrointestinal complications. Results: The cohort included 36,932 patients with 58.3% females and 54.1% THAs. Mean age and BMI were 68 years and 28. Median postoperative LOS was 2 days. Only n: 276 (0.75 %) had a LOS > 4 days or a readmission within 90 days due to a gastrointestinal complication (CI 0.67%–0.84%). Of these, only 34 (0.09%) were graded as severe ileus or gastrointestinal bleeding. Conclusions: The risk of GI-complications within the first 90 postoperative days after fast-track THA and TKA was low (0.75%). [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcome measures such as the Oxford Hip Score (OHS) can capture patient-centered perspectives on outcomes after total hip arthroplasty (THA). The OHS assesses hip pain and functional limitations, but defining interpretation threshold values for the OHS is warranted so that numerical OHS values can be translated into whether patients have experienced clinically meaningful changes. Therefore, we determined the minimal important change (MIC), patient acceptable symptom state (PASS), and treatment failure (TF) threshold values for the OHS at 12 and 24-month follow-up in patients undergoing THA. Methods: This cohort study used data from patients undergoing THA at 1 public hospital between July 2016 and April 2021. At 12 and 24 months postoperatively, patients provided responses for the OHS and for 3 anchor questions about whether they had experienced changes in hip pain and function, whether they considered their symptom state to be satisfactory, and if it was not satisfactory, whether they considered the treatment to have failed. The anchor-based adjusted predictive modeling method was used to determine interpretation threshold values. Baseline dependency was evaluated using a new item-split method. Nonparametric bootstrapping was used to determine 95% confidence intervals (CIs). Results: Complete data were obtained for 706 (69%) of 1,027 and 728 (66%) of 1,101 patients at 12 and 24 months postoperatively, respectively. These patients had a median age of 70 years, and 55% to 56% were female. Adjusted OHS MIC values were 6.3 (CI, 4.6 to 8.1) and 5.2 (CI, 3.6 to 6.7), adjusted OHS PASS values were 30.6 (CI, 29.0 to 32.2) and 30.5 (CI, 29.3 to 31.8), and adjusted OHS TF values were 25.5 (CI, 22.9 to 27.7) and 27.0 (CI, 25.2 to 28.8) at 12 and 24 months postoperatively, respectively. MIC values were 5.4 (CI, 2.1 to 9.1) and 5.0 (CI, 1.9 to 8.7) higher at 12 and 24 months, respectively, in patients with a more severe preoperative state. Conclusions: The established interpretation threshold values advance the interpretation and clinical use of the OHS, and may prove especially beneficial for registry-based evaluations of treatment quality. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Pain after total knee arthroplasty (TKA) is a well‐known clinical problem potentially delaying ambulation and recovery. Perioperative glucocorticoids reduce pain and facilitate early recovery, but the optimal timing and dose are still unknown. High pain catastrophizers have an increased risk of poorly controlled postoperative pain, and moderate to severe pain at 24 h is associated with a risk of pain relapse at 48 h. To evaluate the effect of a repeat moderate dose of glucocorticoids after TKA in high pain catastrophizers presenting with moderate to severe pain 24 h postoperatively, having received preoperative high‐dose glucocorticoids. High pain catastrophizers (Pain Catastrophizing Scale > 20) undergoing TKA are screened 24 h postoperatively and are included if they experience moderate to severe pain (VAS > 30) during a 5 m walk test. The included patients will receive either oral 24 mg dexamethasone (n = 55) or placebo (n = 55) on the evening of Day 1 (~30–37 h) after surgery. In addition, patients receive a standard multimodal analgesic regimen, including paracetamol, celecoxib, local infiltration analgesia, and preoperative dexamethasone (1 mg/kg). Patients will fill out a pain diary for 7 days after surgery. The primary outcome is moderate to severe pain (VAS > 30) during a 5 m walk test on the morning of Day 2 after surgery. The secondary outcomes include cumulated pain at rest and during ambulation, cumulated use of rescue analgesics, quality of sleep, lethargy, dizziness, nausea, satisfaction with the analgesic regimen, length of stay, morbidity, mortality, and reasons for readmissions. Follow‐up is at 8 and 30 days. The data from this study will provide evidence for the effect of a repeated dose of dexamethasone as an analgesic adjuvant in patients undergoing TKA with a high risk of postoperative pain. [ABSTRACT FROM AUTHOR]

Aim: To investigate the effect of femoral head size on blood metal-ion levels caused by taper corrosion in metal-on-polyethylene total hip arthroplasty, comparing 36- to 44-mm heads with 32-mm heads. Methods: In a randomised, controlled, single-blinded trial, 96 patients were allocated to receive either a 32-mm metal head or the largest possible metal head (36–44 mm) that could be accommodated in the thinnest available vitamin E, cross-linked polyethylene insert. Blood metal ion levels were collected at 1- and 2-year follow-ups. Results: At 1-year, metal-ion levels did not differ between the groups. The median (interquartile range) blood-ion levels for the 32-mm versus the 36- to 44-mm group were 0.11 µg/L (0.08–0.15) versus 0.12 µg/L (0.08–0.22), p = 0.546, for cobalt, 0.50 µg/L (0.50–0.59) versus 0.50 µg/L (0.50–1.20), p = 0.059, for chromium and 1.58 µg/L (1.38–2.05) versus 1.48 µg/L (1.14–1.87), p = 0.385, for titanium. At 2 years, there was no difference either and the corresponding values were 0.15 µg/L (0.12–0.24) versus 0.18 µg/L (0.12–0.28), p = 0.682 for cobalt, 0.50 µg/L (0.50–0.50) versus 0.50 µg/L (0.50–0.57), p = 0.554, for chromium and 1.54 µg/L (1.16–1.87) versus 1.42 µg/L (1.01–1.72), p = 0.207 for titanium. Conclusions: The use of the largest possible metal head (36–44 mm) compared to a 32-mm head in metal–on-polyethylene bearings does not appear to elevate blood metal-ion levels up to 2 years postoperatively. As taper corrosion is probably time-dependent, longer-term reports are needed to evaluate the association between large metal heads and blood metal ion levels. Trial registration: ClinicalTrials.gov (reg. ID NCT0231 6704) [ABSTRACT FROM AUTHOR]

Background and purpose -- Venous thromboembolism (VTE) is a serious postoperative complication after total knee arthroplasty (TKA). Use of a tourniquet has shown conflicting results for risk of VTE after TKA. We aimed to investigate the associated risk of VTE after TKA using tourniquet in a fast-track set-up as no previous data exists. Patients and methods -- We performed an observational cohort study from 9 fast-track centers including unilateral primary TKA from 2010-2017 with prospective collection of preoperative risk-factors and complete 90-day follow-up. Use of a tourniquet was registered in the Danish Knee Arthroplasty Register. Postoperative VTE was identified from health records. We performed risk analyses using a mixed-effects logistic regression model adjusting for previously identified risk factors. Results -- Of the 16,250 procedures (39% males, mean age 67.9 [SD 10.0] years, median LOS 2 [interquartile range 2-3]) 12,518 (77%) were performed with a tourniquet. The annual tourniquet usage varied greatly between departments from 0% to 100%, but also within departments from 0% to 99%. There was no significant difference between the 2 groups with 52 (0.42%) VTEs in the tourniquet group vs. 25 (0.67%) in the no-tourniquet group (p = 0.06 for cumulative 90-day incidence of VTE). This association remained statistically insignificant for VTE using tourniquet after adjustment for previously identified risk factors. Conclusion -- We found no association between the use of a tourniquet and increased risk of 90-day VTE after primary fast-track TKA, irrespective of the length of time for which the tourniquet was applied. [ABSTRACT FROM AUTHOR]

Background and purpose -- In existing studies on fasttrack unicompartmental knee arthroplasty (UKA), the majority of surgeries are medial. There are substantial differences between lateral and medial UKA, which is why outcomes cannot automatically be compared. To gain information on the feasibility and safety of fast-track protocols in lateral UKAs, we investigated length of stay (LOS) and early complications after lateral UKA, performed using a fast-track protocol in well-established fast-track centers. Patients and methods -- We retrospectively evaluated prospectively collected data on patients undergoing lateral UKA in a fast-track setup from 2010 to 2018 at 7 Danish fast-track centers. Data on patient characteristics, LOS, complications, reoperations, and revisions was analyzed using descriptive statistics. Safety and feasibility were defined as complication and reoperation rates within 90 days comparable to non-fast track lateral UKA or fast-track medial UKA. Results -- We included 170 of patients with a mean age of 66 (SD 12) years. Median LOS was 1 day (interquartile range 1-1), which was unchanged from 2012-2018. 18% were discharged on the day of surgery. Within 90 days, 7 patients experienced medical complications and 5 patients experienced surgical complications. 3 patients underwent reoperation, 2 were soft tissue revisions and the third was removal of an exostosis due to catching of the patella. 1 patient was revised due to a bearing dislocation. Conclusion -- Our findings suggest that lateral UKA in a fast-track setting is feasible and safe. [ABSTRACT FROM AUTHOR]

Background and purpose -- Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers. Patients and methods -- This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome -- Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery. [ABSTRACT FROM AUTHOR]

Background: Early postoperative mobilization can be hindered by orthostatic intolerance (OI) due to failed orthostatic cardiovascular regulation. The underlying mechanisms are not fully understood and specific data after total knee arthroplasty (TKA) are lacking. Therefore, we evaluated the incidence of OI and the cardiovascular response to mobilization in fast‐track TKA. Methods: This prospective observational cohort study included 45 patients scheduled for primary TKA in spinal anesthesia with a multimodal opioid‐sparing analgesic regime. OI and the cardiovascular response to sitting and standing were evaluated with a standardized mobilization procedure preoperatively, and at 6 and 24 h postoperatively. Hemodynamic variables were measured non‐invasively (LiDCO™ Rapid). Perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, opioid use, and pain during mobilization were recorded. Results: Eighteen (44%) and 8 (22%) patients demonstrated OI at 6 and 24 h after surgery, respectively. Four (10%) and 2 (5%) patients experienced severe OI and terminated the mobilization procedure prematurely. Dizziness was the most common OI symptom during mobilization at 6 h. OI was associated with decreased orthostatic responses in systolic, diastolic, mean arterial pressures, and heart rate (all p <.05), while severe OI patients demonstrated impaired diastolic, mean arterial pressures, heart rate, and cardiac output responses (all p <.05). No statistically significant differences in perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, pain, or opioid use were observed between orthostatic tolerant and intolerant patients. Conclusion: Early postoperative OI is common following fast‐track TKA. Pathophysiologic mechanisms include impaired orthostatic cardiovascular responses. The progression to severe OI symptoms appears to be primarily due to inadequate heart rate response. [ABSTRACT FROM AUTHOR]

Background and purpose -- Developing meaningful thresholds for the Oxford Knee Score (OKS) advances its clinical use. We determined the minimal important change (MIC), patient acceptable symptom state (PASS), and treatment failure (TF) values as meaningful thresholds for the OKS at 3-, 12-, and 24-month follow-up in patients undergoing unicompartmental knee arthroplasty (UKA). Patients and methods -- This is a cohort study with data from patients undergoing UKA collected at a hospital in Denmark between February 2016 and September 2021. The OKS was completed preoperatively and at 3, 12, and 24 months postoperatively. Interpretation threshold values were calculated with the anchor-based adjusted predictive modeling method. Non-parametric bootstrapping was used to derive 95% confidence intervals (CI). Results -- Complete 3-, 12-, and 24-month postoperative data was obtained for 331 of 423 (78%), 340 of 479 (71%), and 235 of 338 (70%) patients, median age of 68--69 years (58--59% females). Adjusted OKS MIC values were 4.7 (CI 3.3--6.0), 7.1 (CI 5.2--8.6), and 5.4 (CI 3.4--7.3), adjusted OKS PASS values were 28.9 (CI 27.6--30.3), 32.7 (CI 31.5-- 33.9), and 31.3 (CI 29.1--33.3), and adjusted OKS TF values were 24.4 (CI 20.7--27.4), 29.3 (CI 27.3--31.1), and 28.5 (CI 26.0--30.5) at 3, 12, and 24 months postoperatively, respectively. All values statistically significantly increased from 3 to 12 months but not from 12 to 24 months. Interpretation -- The UKA-specific measurement properties and clinical thresholds for the OKS can improve the interpretation of UKA outcome and assist quality assessment in institutional and national registries. [ABSTRACT FROM AUTHOR]

Abstract Introduction Implant performance of cementless THA is often evaluated by radiolucency on plain radiographs, often classified as interference gaps on direct post-operative radiographs. However, the diagnostic performance is unknown. The aim was to evaluate the diagnostic performance of radiographic assessment of post-operative gaps after primary THA by comparing it with CT confirmed gaps, and secondary to define optimal cut-off criteria for assessing gaps on plain radiographs compared with CT. Material and methods Patients (N = 40) with a primary cementless THA performed between July 2015 and March 2016 were enrolled in the study. Radiolucency was assessed on post-operative AP pelvic digital radiographs by two observers independently. Maximum width and percentage of coverage per zone were reported. Gap volume was measured by manual segmentation on CT images. Results When defining a gap as a radiolucency extending through >50% of a zone, the interrater agreement Kappa was 0.241. Sensitivity was 65.8% for observer 1 (Kappa = 0.432), and 86.8% for observer 2 (Kappa = 0.383). When defining a gap as a radiolucency with a width >1 mm, the interrater agreement Kappa was 0.302. Sensitivity was 55.3% and 50% for observer 1 and observer 2, respectively. The ROC-curve resulted in an optimal threshold of 0.65 mm (AUROC = 0.888) and 0.31 mm (AUROC = 0.961) for the two observers. Conclusion The diagnostic performance of observers detecting interference gaps on radiographs showed low sensitivity. Further on, the inter-rater agreement is too low to do a general recommendation about thresholds for defining gaps. Evaluating progression of radiolucency on radiographs should be performed in the light of these findings. Highlights • The diagnostic performance of radiographic assessment of gaps showed low sensitivity. • The interrater agreement is too low to define general cut-off criteria for gaps on radiographs. • In clinical settings, the radiolucency measurements can be used to support the clinical symptoms in making a clinical diagnosis, while taking diagnostic limitations into consideration. [ABSTRACT FROM AUTHOR]

Background: While evidence-based indications are established for medial UKA, the optimal indications for lateral UKA have not received as much attention. There exists significant anatomical, osteoarthritis phenotype, kinematic, and surgical technique differences between medial and lateral UKA. The indications for the two procedures may therefore not be identical. Hence, this review aims to access the indications and contraindications in published cohort studies on lateral UKA, to assess if consensus exists., Methods: In May 2024, a systematic review was carried out following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Cohort studies on lateral UKA with a clear report of indications were included. Data on indications and contraindications were extracted to evaluate consensus. Furthermore, outcomes related to expanding or testing indications for lateral UKA were obtained., Results: 38 studies were included. Lateral UKA was mostly performed for primary lateral osteoarthritis. The most reported indications were moderate to severe lateral osteoarthritis, with full-thickness cartilage in the medial compartment, intact ligaments, a correctable valgus deformity, and a flexion contracture < 10-15 degrees. The most reported contraindications were inflammatory arthritis and severe patellofemoral involvement. Eight studies investigated different indications on outcomes after lateral UKA; suggesting better outcomes for primary lateral osteoarthritis, no significant impact from the state of the patellofemoral joint, and conflicting results regarding age and weight., Conclusion: While the literature suggests that some agreement does exist regarding indications for lateral UKA, a strong consensus was not found, indicating that well-defined and consensus-based indications for lateral UKA do not yet exist., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Contemporary evidence-based indications no longer consider age regarding eligibility for medial unicompartmental knee arthroplasty (mUKA). This has led to more surgical candidates; however, whether patients still have satisfactory outcomes lacks evidence. This study examined the association between age and change in patient-reported outcome measures (PROMs) after mUKA as well as the achievement of Patient Acceptable Symptom State (PASS) and Minimal Important Change (MIC)., Methods: We included 782 mUKAs performed between February 1, 2016, and April 26, 2023. The mean change from preoperative Oxford Knee Score (OKS), Forgotten Joint Score (FJS), and Activity and Participation Questionnaire (APQ) was assessed at three, 12, and 24 months after surgery. The achievement of 12-month PASS (OKS ≥ 30) and MIC (changes in OKS ≥ 8; FJS ≥ 14) was also assessed. Patients were divided into age groups: < 55, 55 to < 65, 65 to < 75 years (reference group), and ≥ 75 years. There were 432 women (55%), patients had a mean age of 67 years (range, 29 to 93) and a mean BMI of 30 (range, 20 to 53)., Results: Median OKS, youngest to eldest, were 34, 35, 36, and 35 (three months); 40, 39, 41, and 43 (12 months); 42, 41, 43, and 42 (24 months). We found no differences in change in OKS between groups. Patients aged 55 to < 65 years had lower changes in FJS at 24 months and APQ at 12 and 24 months. Patients ≥ 75 years had lower 24-month change in APQ. We found no association between age and the fraction achieving either PASS or MIC (youngest to eldest, 90, 90, 94, and 95%)., Conclusion: We found good PROM improvements and satisfactory outcomes after mUKA in all age groups; however, patients aged 55 to < 65 years had worse changes in FJS and APQ. Results support contemporary indications for mUKA, and applying an age cutoff is unwarranted., (Copyright © 2024. Published by Elsevier Inc.)

Aims: Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA., Methods: A multicentre, prospective consecutive cohort study was carried out from September 2022 to August 2023. Patients were screened for day-case eligibility using well defined inclusion and exclusion criteria, and discharged when fulfilling predetermined discharge criteria. Day-case eligible patients were scheduled for surgery with intended start of surgery before 1.00 pm., Results: Of 6,142 primary hip and knee arthroplasties, eligibility rates for day-case surgery were 34% for THA (95% CI 32% to 36%), 34% for TKA (95% CI 32% to 36%), and 52% for mUKA (95% CI 49% to 55%). Surgery before 1.00 pm was achieved in 85% of eligible patients. The day-case success rate among patients with surgery before 1.00 pm was 59% (95% CI 55% to 62%) for THA, 61% (95% CI 57% to 65%) for TKA, and 72% (95% CI 68% to 76%) for mUKA. Overall day-case success rates (eligible and non-eligible) were 19% (95% CI 17% to 20%) for THA, 20% (95% CI 18% to 21%) for TKA, and 42% (95% CI 39% to 45%) for mUKA. Adjusted analysis confirmed higher day-case success in eligible mUKA patients (odds ratio 1.9 (1.6 to 2.3)) compared to TKA and THA patients. Primary causes for day-case failure were mobilization issues (9% to 12% between procedures), prolonged spinal anaesthesia (4% to 9%), and postoperative nausea and vomiting (PONV) (4% to 14%)., Conclusion: THA and TKA patients showed comparable eligibility (34%) with similar day-case success rates (59 to 61%), whereas mUKA patients demonstrated higher eligibility (52%) and day-case success (72%). Mobilization issues, prolonged spinal anaesthesia, and PONV were the most frequent causes for not being discharged., Competing Interests: The salary for PhD student O. Danielsen was provided through funding from the Candy's Foundation, the University of Southern Denmark, and the Region of Southern Denmark. C. Varnum received travel expenses from Stryker, which is unrelated to this work. M. R. Andersen is secretary of the Danish Society for Hip and Knee Arthroplasty, which is unrelated. S. Overgaard received personal payment for a lecture from Johnson & Johnson, and institutional payment for being a course moderator and lectures from Heraeus, which are unrelated. C. C. Jørgensen received personal speaker fees and travel support from Pharmacosmos, unrelated to this work. H. Kehlet is on the Zimmer Biomet advisory board on rapid recovery. K. Gromov received research and institutional support from Zimmer Biomet, which was also unrelated., (© 2024 Danielsen et al.)

Background: Preoperative psychopharmacological treatment (PPT) has been associated with increased hospital length of stay and readmission rate after hip and knee arthroplasty. However, little is known regarding the association between PPT and improvements in patient-reported outcomes postoperatively in a multicenter fast-track setting. Thus, the primary objective was to investigate whether PPT is a risk factor for poorer patient-reported improvements 12 months after surgery. Secondary objectives included assessment of additional time points and subgroups of PPT., Methods: This multicenter registry-based cohort study included 4,021 primary hip and 3,226 primary knee arthroplasties performed from 2016 to 2020 at three fast-track departments in Denmark due to primary osteoarthritis. The Oxford Hip Score/Oxford Knee Score (OHS/OKS), EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels, and EuroQol visual analog scale were collected at baseline and 3, 6, 12, and 24 months after surgery. Exposure status was assigned using the Danish National Prescription Registry. Marginal mean differences (MD) with 95% confidence intervals (CIs) were estimated using multilevel Tobit regression and adjusted for age, sex, and the Charlson Comorbidity Index obtained from the Danish National Patient Register., Results: No associations were found between PPT and improvements in OHS (MD -0.5, CI -1.4 to 0.4) or OKS (MD -0.3, CI -1.2 to 0.5) after 12 months. However, PPT was associated with lower baseline OHS (MD -1.4, CI -2.2 to -0.6) and OKS (MD -2.1, CI -2.9 to -1.3), and 12 months follow-up OHS (MD -1.9, CI -2.8 to -1.1) and OKS (MD -2.4, CI -3.2 to -1.6). Similar findings were observed at other time points, using EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels or EuroQol visual analog scale, and when evaluating PPT subgroups., Conclusions: In hip and knee arthroplasty, PPT was not a risk factor for poorer patient-reported improvements 12 months after surgery. However, PPT was associated with marginally poorer baseline and follow-up scores. Thus, arthroplasties remain effective treatments despite PPT from a patient-centered perspective., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Methods for identifying high-pain responders undergoing total knee arthroplasty remain important to improve individualized pain management. This study aimed at evaluating pre- and perioperative predictors of pain on Days 2-7 after total knee arthroplasty., Methods: This is a secondary analysis of data from 227 patients participating in two randomized trials. Pain outcomes were mean pain during walking on Days 2-7 and on Days 2, 4 and 7. Multivariable linear and logistic regressions were carried out in two steps. First, only preoperative available variables including demographics, comorbidities, pain catastrophizing scale and preoperative pain were evaluated while controlling for trial intervention and recruitment site. In the second step, perioperative variables and pain during walking 24 h postoperatively were added., Results: The model with only preoperative predictors for mean pain Days 2-7 showed preoperative pain (R-squared 0.097) as the only predictor. In the second model, adding postoperative available variables, only pain 24 h postoperatively (R-squared 0.248) was significant, with a significant main effect of recruitment site. Results for the separate day analysis similarly showed preoperative pain and pain during walking 24 h postoperatively as predictors. The overall best sensitivity (60%) and specificity (74%) for predicting a high-subacute postoperative pain response on Days 2-7 was with cut-off values of VAS 45.5 (out of 100) for pain during walking 24 h postoperatively., Conclusions: Postoperative pain during walking at 24 h is predictive of subacute postoperative pain on Days 2-7 after total knee arthroplasty, while preoperative pain was only a weak predictor., Significance Statement: This study investigated factors associated with pain after total knee arthroplasty beyond the immediate postoperative period. The analysis revealed significant associations between preoperative pain levels and, particularly, pain 24 h postoperatively, with subsequent subacute pain the following week. These findings can assist in identifying patients who would benefit from enhanced, individualized analgesic interventions to facilitate postoperative recovery., (© 2024 European Pain Federation ‐ EFIC ®.)

Background: In the past, the utilization of lateral unicompartmental knee arthroplasty (UKA) has been limited at national levels, despite the fact that an estimated 10% of patients who have an indication for arthroplasty, present with isolated lateral compartment osteoarthritis (OA). Units dedicated to UKA have reported good outcomes. Identifying patients for the procedure has been less clear, and the procedure has been perceived to be technically more demanding than medial UKA. This may result in a reluctance to start a lateral UKA practice and challenge the early phase. Therefore, this paper aimed to present the outcomes and learning curve when starting up a lateral UKA practice, as this theme remains unelucidated., Methods: There were 85 primary fixed-bearing lateral UKAs, with a minimum of 1-year follow-up, performed between 2016 and 2022 by 2 arthroplasty surgeons with existing UKA practices. The indications were primary (n = 79) or post-traumatic (n = 6) OA. Patient-reported outcome measures (PROMs) were assessed at 3, 12, and 24 months. A cumulative sum (CUSUM) analysis was used to evaluate surgical duration and the 12-month Oxford Knee Score (OKS)., Results: Median (interquartile range) 12-month OKS, activity and participation questionnaire, and Forgotten Joint Score (FJS) were 43 (37.5 to 46), 78 (42.5 to 98.5), and 72 (55 to 90), respectively. The OKS outcomes did not reveal adverse effects from the learning curve. A performance shift in surgical duration was observed around case 33. Kaplan-Meier implant survival reached 95.4% at 7 years for the endpoint "implant revision" and 93.5% for "implant revision or implant addition.", Conclusions: Starting up a lateral UKA practice is safe and efficient for surgeons who have prior medial UKA experience, provided strict adherence to indications. While surgical duration indicated a learning curve over approximately 33 cases, PROMs remained stable, suggesting proficient outcomes irrespective of the learning curve., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Vitamin E-doped cross-linked polyethylene (VEPE) has encouraged the use of larger heads in thinner liners in total hip arthroplasty (THA). However, there are concerns about wear and mechanical failure of the thin liner, especially when metal heads are used. The aim of this randomized controlled trial was to investigate if the use of a large metal head in thin VEPE liner would increase polyethylene wear compared with a standard 32-mm metal head and to compare periacetabular radiolucencies and patient-reported outcomes in THA., Methods: There were 96 candidates for uncemented THA who were randomly allocated to either the largest possible metal head (36 to 44 mm) that could be fitted in the thinnest available VEPE liner (intervention group) or a standard 32-mm metal head (control group). The primary outcome was proximal head penetration, measured with a model-based radiostereometric analysis. Secondary outcomes were periacetabular radiolucencies and patient-reported outcomes. The midterm results of the trial at 5 years are presented., Results: The median total proximal head penetration (interquartile range) was -0.04 mm (-0.12 to 0.02) in the intervention group and -0.03 mm (-0.14 to 0.05) in the control group (P = .691). The rates of periacetabular radiolucencies were 1 of 44 and 4 of 42 (P = .197), respectively. Patient-reported hip function and health-related quality of life did not differ between the groups, but participants in the intervention group reported a higher level of activity (median University of California Level of Activity score 7 versus 6, P = .020). There were 5 revisions caused by dislocations (2), periprosthetic fracture (1), stem subsidence (1), or iliopsoas impingement (1)., Conclusions: Large metal heads in thin VEPE liners did not increase liner wear and were not associated with liner failure 5 years after THA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Pain catastrophizing is associated with acute pain after total knee arthroplasty. However, the association between pain catastrophizing and acute pain after unicompartmental knee arthroplasty (UKA) remains unclear., Methods: We investigated the incidence of predicted high-pain and low-pain responders, based on a preoperative Pain Catastrophizing Scale score >20 or ≤20, respectively, and the acute postoperative pain course in both groups. Patients undergoing UKA were consecutively included in this prospective observational cohort study. Pain at rest and during walking (5 m walk test) was evaluated preoperatively, at 24 hours postoperatively, and on days 2-7 using a pain diary., Results: 125 patients were included, with 101 completing the pain diary. The incidence of predicted high-pain responders was 31% (95% CI 23% to 40%). The incidence of moderate to severe pain during walking at 24 hours postoperatively was 69% (95% CI 52% to 83%) in predicted high-pain responders and 66% (95% CI 55% to 76%) in predicted low-pain responders; OR 1.3 (95% CI 0.5 to 3.1). The incidence of moderate to severe pain at rest 24 hours postoperatively was 49% (95% CI 32% to 65%) in predicted high-pain responders and 28% (95% CI 19% to 39%) in predicted low-pain responders; OR 2.6 (95% CI 1.1 to 6.1; p=0.03). Pain catastrophizing was not associated with increased cumulated pain during walking on days 2-7., Conclusions: The incidence of predicted high-pain responders in UKA was slightly lower than reported in total knee arthroplasty. Additionally, preoperative pain catastrophizing was not associated with acute postoperative pain during walking., Competing Interests: Competing interests: KG and AT have received institutional study funding and honorarium related to educational activities from Zimmer Biomet with no relation to the present study., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Length of hospital stay after hip and knee arthroplasty is about 1 day in Denmark with few patients discharged on the day of surgery. Hence, a protocol for multicenter implementation of discharge on day of surgery has been instituted. We aimed to describe the implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting., Methods: We performed a prospective multicenter study from 7 public hospitals across Denmark. Patients were screened using well-defined in- and exclusion criteria and were discharged on day of surgery when fulfilling functional discharge criteria. The study period was from September 2022 to February 2023 with variable start of implementation. Data from the same centers in a 6-month period before the COVID pandemic from July 2019 to December 2019 was used for baseline control., Results: Of 2,756 primary hip and knee arthroplasties, 37% (95% confidence interval [CI] 35-39) were eligible (range 21-50% in centers) and 52% (range 24-62%) of these were discharged on day of surgery. 21% (CI 20-23) of all patients (eligible and non-eligible) were discharged on day of surgery with a range of 10-31% within centers. This was an additional 15% (CI 13-17, P < 0.001) compared with patients discharged in the control period (6% in 2019)., Conclusion: We found it possible to perform outpatient hip and knee replacement in 21% of patients in a public healthcare setting, probably to be increased with further center experience.

Objectives: The minimal important change (MIC) reflects what patients, on average, consider the smallest improvement in a score that is important to them. MIC thresholds may vary across patient populations, interventions used, posttreatment time points and derivation methods. We determine and compare MIC thresholds for the Oxford Knee Score and Oxford Hip Score (OKS/OHS) at 3 months postoperatively to 12- and 24-month thresholds in patients undergoing knee or hip arthroplasty., Study Design and Setting: This cohort study used data from patients undergoing total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or total hip arthroplasty (THA) at a public hospital between February 2016 and February 2023. At 3, 12, and 24 months postoperatively, patients responded to the OKS/OHS and a 7-point anchor question determining experienced changes in knee or hip pain and functional limitations. We used the adjusted predictive modeling method that accounts for the proportion improved and the reliability of the anchor question to determine MIC thresholds and their mean differences between time points., Results: Complete data were obtained from 695/957 (73%), 1179/1703 (69%), and 1080/1607 (67%) patients undergoing TKA, 474/610 (78%), 438/603 (73%), and 355/507 (70%) patients undergoing UKA, and 965/1315 (73%), 978/1409 (69%), and 1059/1536 (69%) patients undergoing THA at 3, 12, and 24 months, respectively. The median age ranged from 68 to 70 years and 55% to 60% were females. The proportions improved ranged between 83% and 95%. The OKS/OHS MIC thresholds were 0.1, 4.2, and 5.1 for TKA, 1.8, 5.6, and 3.4 for UKA, and 1.3, 6.1, and 6.0 for THA at 3, 12, and 24 months postoperatively, respectively. The reliability ranged between 0.64 and 0.82, and the MIC values increased between three and 12 months but not between 12 and 24 months., Conclusion: Any absence of deterioration in pain and function is considered important at 3 months after knee or hip arthroplasty. Increasing thresholds over time suggest patients raise their standards for what constitutes a minimal important improvement over the first postoperative year. Besides improving our understanding of patients' views on postoperative outcomes, these clinical thresholds may aid in interpreting registry-based treatment outcome evaluations., Competing Interests: Declaration of competing interest A.T. reports a relationship with Zimmer Biomet that includes: consulting or advisory, speaking and lecture fees, and travel reimbursement; a relationship with Pfizer Denmark that includes: board membership and consulting or advisory; and a relationship with Danish Knee Arthroplasty register that includes: board membership. K.G. reports a relationship with Zimmer Biomet that includes: nonfinancial support. Other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Perioperative glycaemic control is important. However, the complexity of guidelines for perioperative diabetes management is complicated due to different and novel antihyperglycaemic medications, limited procedure-specific data and lack of data from implemented fast-track regimens which otherwise are known to reduce morbidity and glucose homeostasis disturbances. Consequently, outcome in patients with diabetes mellitus (DM) after surgery and the influence of perioperative diabetes management on postoperative recovery remains poorly understood., Methods and Analysis: A prospective observational multicentre study involving 8 arthroplasty centres across Denmark with a documented implemented fast-track programme (median length of hospitalisation (LOS) 1 day). We will collect detailed perioperative data including preoperative haemoglobin A1c and antidiabetic treatment in 1400 unselected consecutive patients with DM undergoing hip and knee arthroplasty from September 2022 to December 2025, enrolled after consent. Follow-up duration is 90 days after surgery. The primary outcome is the proportion of patients with DM with LOS >4 days and 90-day readmission rate after fast-track total hip arthroplasty (THA), total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). The secondary outcome is the association between perioperative diabetes treatment and LOS >2 days, 90-day readmission rate, other patient demographics and Comprehensive Complication Index for patients with DM after THA/TKA/UKA in a fast-track regimen., Ethics and Dissemination: The study will follow the principles of the Declaration of Helsinki and ICH-Good Clinical Practice guideline. Ethical approval was not necessary as this is a non-interventional observational study on current practice. The trial is registered in the Region of Southern Denmark and on ClinicalTrials.gov. The main results and all substudies of this trial will be published in peer-reviewed international medical journals., Trial Registration Number: NCT05613439., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Early postoperative mobilization is essential for early functional recovery but can be inhibited by postoperative orthostatic intolerance (OI). Postoperative OI is common after major surgery, such as total knee arthroplasty (TKA). However, limited data are available after less extensive surgery, such as unicompartmental knee arthroplasty (UKA). We, therefore, investigated the incidence of OI as well as cardiovascular and tissue oxygenation responses during early mobilization after UKA., Methods: This prospective single-centre observational study included 32 patients undergoing primary UKA. Incidence of OI and cardiovascular and tissue oxygenation responses during mobilization were evaluated preoperatively, at 6 and 24 h after surgery. Perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain during mobilization and opioid usage were recorded., Results: During mobilization at 6 h after surgery, 4 (14%, 95%CI 4-33%) patients experienced OI; however, no patients terminated the mobilization procedure prematurely. Dizziness and feeling of heat were the most common symptoms. OI was associated with attenuated systolic and mean arterial blood pressure responses in the sitting position (all p < 0.05). At 24 h after surgery, 24 (75%) patients had already been discharged, including three of the four patients with early OI. Only five patients were available for measurements, two of whom experienced OI; one terminated the mobilization procedure due to intolerable symptoms. We observed no statistically significant differences in perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain, or opioid usage between orthostatic intolerant and tolerant patients., Conclusions: The incidence of orthostatic intolerance after fast-track unicompartmental knee arthroplasty is low (~ 15%) and is associated with decreased orthostatic pressure responses. Compared to the previously described orthostatic intolerance incidence of ~ 40% following total knee arthroplasty, early orthostatic intolerance is uncommon after unicompartmental knee arthroplasty, suggesting a procedure-specific component., Trial Registration: Prospectively registered at ClinicalTrials.gov; registration number: NCT04195360, registration date: 13.12.2019., (© 2024. The Author(s).)