A systematic review of psychological interventions in total hip and knee arthroplasty Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. Benefit–risk assessment of rivaroxaban versus enoxaparin for the prevention of venous thromboembolism after total hip or knee arthroplasty Effect of postoperative reinfusion systems on hemoglobin levels in primary total hip and total knee arthroplasties. A prospective randomized study. Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Perioperative risk factors for deep vein thrombosis after total hip arthroplasty or total knee arthroplasty. Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial. The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty—a population-based study Clinical efficacy of postoperative autologous transfusion of filtered shed blood in hip and knee arthroplasty. Fast-track hip and knee replacement — what are the issues? Small Increase of Actual Physical Activity 6 Months After Total Hip or Knee Arthroplasty Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. Effects of steroids on thrombogenic markers in patients undergoing unilateral total knee arthroplasty: a prospective, double-blind, randomized controlled trial. IgG-class anti-PF4/heparin antibodies and symptomatic DVT in orthopedic surgery patients receiving different anti-thromboembolic prophylaxis therapeutics The effect of cold therapy on the postoperative course of total hip and knee arthroplasty patients. Randomized Trials to Modify Patients’ Preoperative Expectations of Hip and Knee Arthroplasties Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty. Comparison of lifetime incremental cost:utility ratios of surgery relative to failed medical management for the treatment of hip, knee and spine osteoarthritis modelled using 2-year postsurgical values. Low-molecular-weight heparin and partial thromboplastin time-adjusted unfractionated heparin in thromboprophylaxis after total knee and total hip arthroplasty. An individualized pre-operative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty.
Background The current practice in elective orthopaedics does not routinely include psychological interventions despite evidence that psychological factors such as personality , anxiety , depression and negative thinking styles can influence outcomes and recovery from surgery . The objective of this paper was to review the effectiveness of psychological interventions used in conjunction with total hip ( THA ) and knee arthroplasty ( TKA ) , in improving patient reported joint outcomes . Methods An extensive literature search was conducted according to Preferred Reporting Items for Systematic review s and Meta-Analyses guidelines . Search terms included psychology , interventions , and orthopaedics . Articles were included if they were r and omised controlled trials ( RCTs ) of psychological interventions involving active patient participation measured with patient reported joint outcomes in patients undergoing hip or knee arthroplasty . Results A total of 19,489 titles were screened . Seven studies met the inclusion criteria and were included . Five of seven studies did not show improvements in patient reported outcomes after surgery . Specifically , psycho-education alone was not effective at improving patient reported joint outcomes in two out of two studies . Conclusion The current literature does not support routine psychological interventions for TKA and THA . However , it should be noted that the literature for psychological interventions in conjunction with TKA and THA is still in its infancy . This gap in the literature is surprising , considering the importance of the role of psychological factors in recovery . Further RCTs with long term follow ups , multidisciplinary involvement , and more comprehensive and focused interventions that go beyond educating patients are needed . Future studies should account for the dem and effect , include measures of psychological variables to determine whether psychological interventions are more beneficial for some patients compared to others , and compare the different modes of delivery and timing of interventions to determine the optimal nature and duration of psychological interventions for TKA and THA In this prospect i ve r and omized study , patients undergoing total hip ( THA ) or knee arthroplasty ( TKA ) were r and omized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block ( TKA patients ) . All patients received a comprehensive multimodal perioperative protocol .  Pain , recovery of functional milestones , and overall satisfaction were assessed . The THA study group demonstrated significantly lower average pain scores and higher overall satisfaction than the control group . There was no significant difference in pain scores between the study and control groups in the TKA cohort . Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery . Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities Purpose Venous thromboembolism is a common complication after major orthopedic surgery . When prescribing anticoagulant prophylaxis , clinicians weigh the benefits of thromboprophylaxis against bleeding risk and other adverse events . Previous benefit – risk analyses of the REgulation of Coagulation in ORthopaedic surgery to prevent Deep vein thrombosis and pulmonary embolism ( RECORD ) r and omized clinical studies of rivaroxaban versus enoxaparin  after total hip ( THA ) or knee ( TKA ) arthroplasty generally used pooled THA and TKA results , counted fatal bleeding as both an efficacy and a safety event , and included the active and placebo-controlled portions of RECORD2 , which might confound benefit – risk assessment s. We conducted a post hoc analysis without these constraints to assess benefit – risk for rivaroxaban versus enoxaparin in the RECORD studies . Patients and methods Data from the safety population of the two THA and two TKA studies were pooled separately . The primary analysis compared the temporal course of event rates and rate differences between rivaroxaban and enoxaparin prophylaxis for symptomatic venous thromboembolism plus all-cause mortality ( efficacy events ) versus nonfatal major bleeding ( safety events ) . Additionally , these rates were used to derive measures of net clinical benefit , number needed to treat ( NNT ) , and number needed to harm ( NNH ) for these two end points . Results After THA or TKA , and compared with enoxaparin , rivaroxaban therapy result ed in more efficacy events prevented than safety events caused , with benefits exceeding harms early and throughout treatment and follow-up . Relative to enoxaparin , rivaroxaban treatment prevented six efficacy events per harm event caused for THA , with NNT = 262/NNH = 1,711 . For TKA , rivaroxaban treatment prevented four to five efficacy events per harm event caused , with NNT = 102/NNH = 442 . Sensitivity analysis that included surgical-site bleeding result ed in NNH = 345 for THA and NNH = 208 for TKA . Conclusion In the RECORD studies , considering death , symptomatic venous thromboembolism , and major bleeding , rivaroxaban result ed in greater benefits than harms compared with enoxaparin . When incorporating surgical-site bleeding , rivaroxaban also results in greater benefit than harm for TKA and is balanced with enoxaparin for THA A prospect i ve r and omized study was undertaken to quantify the effect of reinfusion of postoperative shed blood drainage on the hemoglobin levels in patients undergoing elective primary total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) . One hundred eleven patients were enrolled between December 1990 and August 1991 . There were 42 THAs and 69 TKAs . The study group consisted of 57 patients ( 35 TKAs and 22 THAs ) who received a CBC ConstaVac ( Stryker Surgical , Kalamazoo , MI ) reinfusion system .  The control group consisted of 54 patients ( 34 TKAs and 20 THAs ) who received a ConstaVac collection unit .  Postoperative drainage volumes were recorded for both groups . In addition , the volume of reinfused blood was recorded for the study group . Postoperative hemoglobins were recorded on postoperative days 1 , 3 , and 6 , the latter reflecting the discharge hemoglobin level . All patients were encouraged to predeposit two units of autologous blood for both THAs and TKAs . This study showed no statistically significant difference in the postoperative hemoglobin levels between the study and control groups at anytime . Additionally , there was no statistically significant difference between hemoglobin levels and drainage volumes in both the THA and TKA study groups , compared to their respective control groups . The results of this study suggest that reinfusion units are not necessary in THAs and TKAs as a matter of routine use Abstract There have been several attempts to reduce postoperative blood loss in patients undergoing total arthroplasty . Benoni et al. reported the usefulness of tranexamic acid in total knee arthroplasty ( TKA ) . We investigated its effect in TKA and total hip arthroplasty ( THA ) . Blood loss was significantly reduced in patients given tranexamic acid  in both the TKA and THA groups , and no severe complications , such as venous or pulmonary thrombosis , were noted in any of the patients who received the agent . Administration of tranexamic acid seems to be useful for reducing postoperative blood loss in TKA and THA OBJECTIVE To evaluate if the timing of aquatic therapy influences clinical outcomes after total knee arthroplasty ( TKA ) or total hip arthroplasty ( THA ) . DESIGN Multicenter r and omized controlled trial with 3- , 6- , 12- , and 24-month follow-up . SETTING Two university hospitals , 1 municipal hospital , and 1 rural hospital . PARTICIPANTS Patients ( N=465 ) undergoing primary THA ( n=280 ) or TKA ( n=185 ) : 156 men , 309 women . INTERVENTION Patients were r and omly assigned to receive aquatic therapy ( pool exercises aim ed at training of proprioception , coordination , and strengthening ) after 6 versus 14 days after THA or TKA . MAIN OUTCOME MEASURES Primary outcome was self-reported physical function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) at 3- , 6- , 12- , and 24-months postoperatively . Results were compared with published thresholds for minimal clinical ly important improvements . Secondary outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey , Lequesne-Hip/Knee-Score , WOMAC-pain and stiffness scores , and patient satisfaction . RESULTS Baseline characteristics of the 2 groups were similar . Analyzing the total study population did not result in statistically significant differences at all follow-ups . However , when performing sub analysis for THA and TKA , opposite effects of early aquatic therapy were seen between TKA and THA . After TKA all WOMAC subscales were superior in the early aquatic therapy group , with effect sizes of WOMAC physical function ranging from .22 to .39 . After THA , however , all outcomes were superior in the late aquatic therapy group , with WOMAC effect sizes ranging from .01 to .19 . However , the differences between treatment groups of these subanalyses were not statistically significant . CONCLUSIONS Early start of aquatic therapy had contrary effects after TKA when compared with THA and it influenced clinical outcomes after TKA . Although the treatment differences did not achieve statistically significance , the effect size for early aquatic therapy after TKA had the same magnitude as the effect size of nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis of the knee . However , the results of this study do not support the use of early aquatic therapy after THA . The timing of physiotherapeutic interventions has to be clearly defined when conducting studies to evaluate the effect of physiotherapeutic interventions after TKA and THA STUDY OBJECTIVE To determine the perioperative frequency of  deep vein thrombosis ( DVT ) after lower limb joint prosthesis surgery using Doppler ultrasonography ( US ) . DESIGN Prospect i ve cohort study . SETTING Operating room and hospital ward . PATIENTS 144 consecutive ASA physical status 1 and 2 patients who underwent elective total hip arthroplasty ( THA ; n=64 ) or total knee arthroplasty ( TKA ; n= 80 ) . INTERVENTIONS Patients were allocated to two groups , those who developed DVT ( DVT group ) postoperatively and those who did not ( no-DVT group ) . To examine the perioperative risk factors for DVT after THA or TKA , comparative analysis of the two groups was done . MEASUREMENTS Doppler US was performed on all patients from the bilateral femoral to lower limb to detect the existence of DVT postoperatively . MAIN RESULTS DVT was detected in 61 patients ( 42 % ) , including three proximal DVT patients ( 2 % ) . Preoperative elevated plasma D-dimer value [ P = 0.0131 , odds ratio ( OR ) 1.54 , 95 % CI 1.10 - 2.17 ] and history of hyperlipidemia ( P = 0.0453 , OR 6.92 , 95 % CI 1.04 - 46.00 ] were significant risk factors for the onset of DVT . A preoperative plasma D-dimer cutoff value as a diagnostic test was obtained as 0.85 μg/mL. CONCLUSIONS A high preoperative plasma D-dimer value and /or history of hyperlipidemia were risk factors for DVT after THA or TKA BACKGROUND Postoperatively shed blood salvage is commonly used to reduce allogenic blood transfusion in patients undergoing total hip ( THA ) and knee arthroplasty ( TKA ) . Autologous blood retransfusion is not devoid of risk . We hypothesized that adding tranexamic acid ( TXA ) to a restrictive blood transfusion protocol would reduce the need for postoperative autologous blood retransfusion in primary knee and hip arthroplasty . STUDY DESIGN AND METHODS Ninety-eight adult patients undergoing primary THA or TKA were r and omly assigned to receive an intraoperative intravenous loading dose of 1.0 g of TXA followed by another 1.0-g dose 3 hours later ( TXA group ) or a matching volume 0.9 % saline placebo ( control group ) . A postoperatively shed autologous blood recovery system was used in all patients and the minimum reinfusion volume set at 250 mL. Red blood cells were transfused if hemoglobin level was less than 8 or if 8 to 10 g/dL with symptoms of anemia . RESULTS The proportion of patients receiving autologous blood reinfusion was significantly lower in the TXA group ( 5/49 ) compared to placebo ( 42/49 ) with an absolute difference of -75.5 % ( adjusted relative risk , 0.005 ) , and none of the patients in the TXA group received more than 400 mL retransfused . Median total external blood loss during the first 24 hours was lower in the TXA group , 320 mL ( range , 80 - 930 mL ) , compared to 970 mL ( range , 100 - 2600 mL ) in the placebo group ( p < 0.001 ) . There were no significant differences in homologous blood transfusions and hematologic variables between groups . Treatment differences were consistent by size and significance when the analysis was repeated separately in patients undergoing TKA or THA . CONCLUSION Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary Abstract The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest . Although mainly neuraxial vs general anesthesia has been addressed , population -level data on the impact of peripheral nerve blocks ( PNBs ) are still lacking . Therefore , we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties ( total hip arthroplasty [THA]/total knee arthroplasty [ TKA ] ) from the national Premier Perspective data base ( 2006 - 2013 ) . Multilevel multivariable logistic regression models measured associations between PNB use and outcomes . Complications included cardiac , pulmonary , gastrointestinal and renal complications , cerebrovascular events , infections , wound complications , thromboembolic complications , inpatient falls , and mortality . Re source utilization variables included blood transfusions , intensive care unit admissions , opioid consumption , cost , and length of stay . Overall , 12.5 % of patients received a PNB , with an increase over time particularly among TKAs . Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA . Notable beneficial effects were seen for wound complications ( odds ratio 0.60 [ 95 % confidence interval , 0.49 - 0.74 ] ) among THA recipients and pulmonary complications ( odds ratio 0.83 [ 95 % confidence interval , 0.72 - 0.94 ] ) in patients with TKA . Peripheral nerve block use was significantly ( P < 0.0001 ) associated with a −16.2 % and −12.7 % reduction in opioid consumption for patients with THA and TKA , respectively . In conclusion , our results indicate that PNBs might be associated with superior perioperative population -level outcomes . In light of the inability to establish a causal relationship and the presence of residual confounding , we strongly advocate for further prospect i ve investigation , ideally in multicenter , r and omized trials , to establish the potential impact of PNBs on outcomes on a population level BACKGROUND Total knee arthroplasty ( TKA ) or total hip arthroplasty ( THA ) regularly results in postoperative requirement of blood transfusion . Because of the disadvantages of allogeneic blood transfusion ( ABT ) such as the risk of transfusion-associated infections , incompatibility-related transfusion fatalities , or immunomodulatory effects , a continuing effort to reduce allogeneic blood transfusion is important . For this purpose , the effect of reinfusion of drain blood , via a postoperative wound drainage and reinfusion system , on the need for allogeneic blood transfusion was evaluated . STUDY DESIGN AND METHODS Using a prospect i ve observational quality assessment design , we compared 135 patients scheduled for TKA or THA with a historic group of 96 patients . In the study group the Bellovac ABT autotransfusion system was used . The shed blood was returned either when 500 mL were collected or at most 6 hours after surgery . Compared were the preoperative , postoperative , and discharge hemoglobin , as well as the number of allogeneic blood transfusions . RESULTS There were no statistical differences between preoperative , postoperative , and discharge hemoglobin levels . Autologous transfusion reduced the number of patients receiving ABT overall from 35 percent ( control ) to 22 percent ( study ) . The decrease of allogeneic transfusion requirement was most significant after TKA : from 18 percent to 6 percent ( p < 0.001 ) . CONCLUSION We conclude that the Bellovac ABT device reduces allogeneic blood transfusions in TKA and THA Surgical injury is followed by pain , stress-induced catabolism , impairment of organ function , and a risk of thromboembolism and impaired cognitive function . These events may contribute to complications , a need for prolonged hospitalization , postoperative fatigue , delayed convalescence , and the need for rehabilitation . Optimization of the individual care components in perioperative care ( the fast-track methodology ) reduces the need for hospitalization , morbidity , and prolonged convalescence , with subsequent economic savings ( Kehlet and Wilmore 2008 ) . Correspondingly , improvement in perioperative care has led to a reduced stay in hospital after total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) , which is now only about 3 days in many centers . The main question that remains to be answered is whether further improvement can be made and whether these operations can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications , long-term cognitive dysfunction , pain , and need for rehabilitation . Thus , a multidisciplinary collaboration has been established in 5 dedicated public Danish hospitals with established fast-track THA and TKA in order to optimize perioperative care to require only 1–2 days of hospitalization with no increase in post-discharge pain , morbidity , and rehabilitation requirements ( Figure ) . To this end , we concentrated on  perioperative pain management , optimization of transfusion strategies , strategies for postoperative rehabilitation , requirements for postoperative thromboembolic prophylaxis , and safety aspects ( re-admissions , hip dislocation , and knee stiffness ) . Effective postoperative pain relief is a prerequisite for a successful fast-track recovery . Although continuous peripheral nerve blocks are currently the most effective analgesic techniques ( Ilfeld et al. 2008a , b ) , they are dem and ing in terms of expertise and there is a risk of muscle paralysis . Efforts have therefore been made recently to improve local wound infiltration and infusion techniques . Although promising , more research is required to better define these techniques regarding dose-volume relationships , placement and types of catheters , duration , and safety aspects ( Rostlund and Kehlet 2007 ) . There will be more focus on post-discharge pain , which remains a problem in many patients . Furthermore , research will concentrate on mechanisms and predictors of the large inter-individual variability in the degree of postoperative pain , which may be related to the inflammatory response and genes associated with pain . Such knowledge should facilitate pain management , leading to differential use of analgesic principles in low pain responders and high-pain responders . Blood transfusion is indicated when a patient 's limit concerning — or physiological adaptation to — progressive normovolemic anemia is reached , but there are no specific data from THA and TKA . Data from hip fracture surgery have shown that postoperative anemia impedes functional mobility and that a liberal transfusion strategy reduces morbidity ( Foss et al. 2009 ) . Since modern blood transfusion is safer than before , large r and omized studies with high and low transfusion thresholds will be performed in cardiovascular high-risk patients after THA , with morbidity and functional recovery as primary outcome measures . Postoperative rehabilitation after THA and TKA has been st and ard despite the fact that there has been little evidence on the optimal type of physiotherapy , when it should be started , and for how long ( Minns Lowe et al. 2007 , 2009 ) . Previous r and omized studies have been inconclusive and they were based on relatively long-term hospitalization ( 7–12 days ) ; they are therefore not applicable to fast-track THA and TKA . Over the last decade , many industry-sponsored trials have documented the need for prolonged thromboembolic prophylaxis ( 10–30 days ) , mostly based on surrogate outcomes and with relatively small effects on clinical manifestations of thromboembolism ( Geerts et al. 2008 ) . A common characteristic of these studies has been a relatively long hospital stay ( 6–12 days or more ) . Since postoperative immobilization is a well-known risk factor for postoperative thromboembolism , the need for prolonged thromboembolic prophylaxis after implementation of fast-track surgery with early mobilization might be question ed . The fast-track group will therefore focus on a large ( n = 5,000 ) prospect i ve , detailed 90-day follow-up study with prophylaxis only until discharge ( 1–3 days ) . It is well-documented that cognitive function declines after THA and TKA in elderly patients ( Maze et al. 2008 ) . A fast-track setup may reduce cognitive dysfunction due to less postoperative sleep disturbances , less pain , and less opioid requirements , all of which may impair cognitive function . Finally , in the fast-track THA and TKA setting , safety aspects will be assessed regarding the risk of hip dislocation , and knee stiffness after TKA . In summary , despite major improvements in care and short-term outcome after THA and TKA , several issues remain to be answered in order to optimize fast-track treatment Abstract Limitation in daily physical activity is one of the reasons for total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) . However , studies of the effects of THA or TKA generally do not determine actual daily activity as part of physical functioning . We determined the effect of THA or TKA on patients ’ actual physical activity and body function ( pain , stiffness ) , capacity to perform tasks , and self-reported physical functioning . We also assessed whether there are differences in the effect of the surgery between patients undergoing THA or TKA  and whether the improvements vary between these different outcome measures . We recruited patients with long-st and ing end-stage osteoarthritis of the hip or knee awaiting THA or TKA .  Measurements were performed before surgery and 3 and 6 months after surgery . Actual physical activity improved by 0.7 % . Patients ’ body function , capacity , and self-reported physical functioning also improved . The effects of the surgery on these aspects of physical functioning were similar for THA and TKA . The effect on actual physical activity ( 8 % ) was smaller than on body function ( 80%–167 % ) , capacity ( 19%–36 % ) , and self-reported physical functioning ( 87%–112 % ) . Therefore , in contrast to the large effect on pain and stiffness , patients ’ capacity , and their self-reported physical functioning , the improvement in actual physical activity of our patients was less than expected 6 months after surgery . Level of Evidence : Level I , prospect i ve study . See the Guidelines for Authors for a complete description of levels of evidence OBJECTIVE To evaluate the effect of a short preoperative exercise intervention on the functional status , pain , and muscle strength of patients before and after total joint arthroplasty . METHODS A total of 108 men and women scheduled for total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) were r and omized to a 6-week exercise or education ( control ) intervention immediately prior to surgery . We assessed outcomes through question naires and performance measures . Analyses examined differences between groups over the preoperative and immediate postoperative periods and at 8 and 26 weeks postsurgery . RESULTS Among THA patients , the exercise intervention was associated with improvements in preoperative Western Ontario and McMaster Universities Osteoarthritis Index function score ( improvement of 2.2 in exercisers versus decline of 3.9 in controls ; P = 0.02 ) and Short Form 36 physical function score ( decline of 0.4 in exercisers versus decline of 14.3 in controls ; P = 0.003 ) . No significant differences were seen in TKA patients . Exercise participation increased muscle strength preoperatively ( 18 % in THA patients and 20 % in TKA patients ) , whereas the control patients had essentially no change in strength ( P > 0.05 for exercise versus education in both THA and TKA groups ) . Exercise participation prior to total joint arthroplasty substantially reduced the risk of discharge to a rehabilitation facility in THA and TKA patients ( adjusted odds ratio 0.27 , 95 % confidence interval 0.074 - 0.998 ) . The intervention had no effects on outcomes 8 and 26 weeks postoperatively . CONCLUSION A 6-week presurgical exercise program can safely improve preoperative functional status and muscle strength levels in persons undergoing THA . Additionally , exercise participation prior to total joint arthroplasty dramatically reduces the odds of inpatient rehabilitation BACKGROUND Preoperative anemia has been associated with increased risk of allogeneic blood transfusion and postoperative morbidity and mortality . The prevalence of preoperative anemia and its association with postoperative outcomes has not previously been reported in relation to fast-track  elective total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) . We aim ed to evaluate the prevalence of preoperative anemia in elective fast-track THA and TKA and its association with risk of perioperative transfusion , prolonged length of hospital stay ( LOS ) , and postoperative readmission . STUDY DESIGN AND METHODS This was a prospect i ve observational data base study with data obtained from six high-volume Danish fast-track surgical centers . Preoperative hemoglobin and patient demographics were collected prospect ively using question naires while outcome and transfusion data were collected using national data bases and patient charts . Adjusted risk estimates for transfusion , prolonged LOS , and all-cause readmission according to preoperative anemia status were obtained by multivariate logistic regression . RESULTS A total of 5.165 THA or TKA procedures were included with a mean patient age of 67 ± 11 years and a median LOS of 2 ( interquartile range , 2 - 3 ) days . A total of 662 patients ( 12.8 % ) had preoperative anemia  according to World Health Organization classification . Preoperative anemia was associated with increased risk of receiving transfusion during admission ( odds ratio [ OR ] , 4.7 ; 95 % confidence interval [ CI ] , 3.8 - 5.8 ) , increased risk of readmission within 90 days from surgery ( OR , 1.4 ; 95 % CI , 1.1 - 1.9 ) , and increased risk of LOS of more than 5 days ( OR , 2.5 ; 95 % CI , 1.9 - 3.4 ) after adjustment for preoperative patient-related risk factors . CONCLUSION Preoperative anemia in elective fast-track THA and TKA is independently associated with transfusion and increased postoperative morbidity , supporting the need for preoperative evaluation and treatment OBJECTIVE To quantify the magnitude of change seen with pain , function , and quality of life outcomes 6 months after  total hip and knee arthroplasties ( THA , TKA )  within a community based cohort of a regional health district . METHODS An inception cohort of 504 patients who received primary THA ( 228 ) or TKA ( 276 ) was prospect ively followed . All patients resided in the community and were assessed within one month prior to surgery and 6 months postoperatively . Health related quality of life measures were evaluated with the Western Ontario and McMaster Universities ( WOMAC ) Osteoarthritis Index and the Medical Outcome Survey Short Form SF-36 . Perioperative factors were extracted from medical charts . Health services utilization data were collected from regional health data bases . RESULTS Over 75 % of patients reported improvement in joint-specific pain and function , regardless of the type of joint replaced . Other health dimensions such as social function , bodily pain , physical function , vitality , and general health showed significant improvement after surgery . Those psychosocial dimensions with modest changes had baseline values comparable to age and sex adjusted normal values ; whereas , bodily pain and physical function , which had large changes , had values lower than the normal values . Ninety-one percent of patients receiving THA were satisfied with their surgery , whereas 77 % were satisfied with their TKA . The average length of stay was 7 days and the in-hospital complication rate was 0.34 per patient . CONCLUSION Large improvements were reported for pain and function after joint arthroplasties , while small to moderate changes were seen in other areas related to quality of life .  Patients with hip arthroplasties showed greater improvement in pain and function and were more satisfied with their outcomes than patients with knee arthroplasties . Although pain and function show large improvements , bodily pain and physical function were less than the values reported in the general population Venous thromboembolism ( VTE ) remains an important complication after total knee arthroplasty ( TKA ) . Systemic thrombin generation starts perioperatively . Inflammation , characterized by a rise in interleukin-6 ( IL6 ) , initiates the coagulation cascade , but low-dose steroids can reduce post-TKA IL6 levels . This double-blinded , r and omized , placebo-controlled study enrolled 30 patients undergoing unilateral TKA to assess the effect of perioperative steroids on serum prothrombin fragment ( PF1.2 ) , a marker of thrombin generation , and plasmin-alpha-2-antiplasmin complex ( PAP ) , a marker of fibrinolysis . Study patients received 100 mg of intravenous hydrocortisone 2 h prior to surgery , and controls received normal saline . Blood sample s , drawn pre-incision and at 4 h post tourniquet release , were assayed for PF1.2 and PAP . The study group had significantly lower mean PF1.2 at 4 h compared to controls ( 616 ± 358 pMol/L vs. 936 ± 332 pMol/L , p = 0.037 ) . The mean rise in PF1.2 in the control group was significantly greater compared to the study group ( 672 ± 173 pMol/L vs. 350 ± 211 pMol/L , p < 0.001 ) . Mean PAP was higher in the study group at 4 h ( 1639 ± 823 µg/L vs. 1087 ± 536 µg/L ) , but did not reach statistical significance ( p = 0.07 ) . These results may have clinical implication s in terms of postoperative VTE risk and management Background Heparin-induced thrombocytopenia ( HIT ) is a thromboembolic complication that can occur with unfractionated heparin ( UFH ) or low molecular weight heparin ( LMWH ) . Our objective was to determine and compare the incidence of IgG-class HIT antibodies in patients undergoing total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) with different antithrombotic prophylaxis therapies  and their contributions to the occurrence of venous thromboembolism ( VTE ) . Methods A prospect i ve observational study was performed for 374 Japanese patients undergoing THA or TKA to determine the incidence of VTE .  IgG-class anti-PF4/heparin antibodies were measured using IgG-specific EIA before and after the operation . Results In the clinical outcome , the incidence of symptomatic deep vein thrombosis ( DVT ) was 15.0 % ( 56/374 , TKA ; 35 , THA ; 21 ) and pulmonary emboli ( PE ) were not observed . The total seroconversion incidence of IgG-class PF4/heparin antibodies was 19.8 % ( 74/374 ) . The seroconversion incidence of IgG-class PF4/heparin antibodies was higher in patients receiving UFH ( 32.7 % ) compared to those receiving LMWH ( 9.5 % ) or fondaparinux ( 14.8 % ) . Furthermore , the seroconversion incidence was significantly higher in patients undergoing TKA compared to those undergoing THA . Based on multivariate analysis , seroconversion of the IgG-class PF4/heparin antibodies was independent a risk factor for symptomatic DVT . Conclusion Our findings show that the seroconversion of IgG-class anti-PF4/heparin antibodies differed with various anti-thrombotic prophylaxis therapeutics and was associated with the risk of DVT in a subset of patients undergoing total joint arthroplasty ( TKA and THA ) Fifty total hip arthroplasty ( THA ) patients and 24 total knee arthroplasty ( TKA ) patients were r and omized in a controlled study to examine the effects of cold therapy ( via thermal blankets ) in the postoperative period . The postoperative hospital stay was significantly shorter for the cold-therapy ( 50 degrees F ) compared with control ( 70 degrees F ) groups ( by 1.4 days , P = 0.03 ) for THA patients . There was a similar but nonsignificant trend observed in the TKA groups ( 1.5 days shorter , P = 0.19 ) . Total knee arthroplasty patients using cold therapy  achieved independent ambulation an average of 1 day sooner than TKA control patients , but this difference did not reach statistical significance ( P = 0.08 ) . There were no statistically significant differences between the control groups or the test groups for both THA and TKA patients in narcotic usage , postoperative range-of-motion ( ROM ) , or rate of progression of ROM Abstract Patients have multiple expectations of THA and TKA . We asked whether preoperative educational classes addressing recovery during the first year could modify patients ’ expectations of their 12-month postoperative recovery . Participants were enrolled consecutively in two r and omized , controlled trials , one for THA ( 177 patients ) and one for TKA ( 143 patients ) . Control patients preoperatively received a st and ard THA or TKA class addressing recovery immediately after surgery . Intervention patients preoperatively received the st and ard class plus a joint-specific module addressing recovery during the first 12 months . Before and after the class , patients completed either a hip-specific or knee-specific vali date d expectations survey . The main outcome was the within-patient change in expectation scores ( maximum increase , + 100 ; maximum decrease , −100 ) before and after the class but preoperatively . Mean changes in hip scores were + 3.3 ± 8 for intervention patients ( range , −22–+32 ) and + 4.9 ± 8 for control patients ( range , −13–+29 ) . Mean changes in knee scores were −3.4 ± 10 for intervention patients ( range , −26–+33 ) and + 2.4 ± 10 for control patients ( range , −30–+30 ) . Patients ’ preoperative expectations of their recovery from THA or TKA can be modified by preoperative educational classes . Level of Evidence : Level I , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence Postoperative length of stay ( LOS ) may be affected by more intensive physical therapy following surgery . This study was design ed to assess whether LOS could be affected by weekend physical therapy following surgery in patients who had undergone total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) . Weekend coverage for these patients was made possible by increased staffing in the Physical Therapy Department . The study group consisted of 84 patients who had undergone THA or TKA and had physical therapy treatment the weekend following surgery . The Control group consisted of 53 patients who had undergone THA or TKA prior to the implementation of the weekend intervention program .  A retrospective chart audit was used to obtain pertinent information about control group patients . In the total sample mean LOS following weekend therapy ( 10.84 days ) was significantly different ( p < 0.05 ) from mean LOS prior to implementation of the study ( 12.28 days ) . Significant decreases in postoperative LOS were also found within the two subgroups of patients who had undergone THA and TKA . The results indicate that physical therapy treatment the weekend following THA or TKA significantly decreases postoperative LOS when physical therapy re sources are increased to accommo date this increase in coverage BACKGROUND Dem and for surgery to treat osteoarthritis ( OA ) of the hip , knee and spine has risen dramatically . Whereas total hip ( THA ) and total knee arthroplasty ( TKA ) have been widely accepted as cost-effective , spine surgeries ( decompression , decompression with fusion ) to treat degenerative conditions remain underfunded compared with other surgeries . METHODS An incremental cost-utility analysis comparing decompression and decompression with fusion to THA and TKA , from the perspective of the provincial health insurance system , was based on an observational matched-cohort study of prospect ively collected outcomes and retrospectively collected costs . Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period . Utility was modelled over the lifetime , and quality -adjusted life years ( QALYs ) were determined . We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3 % . Sensitivity analyses were also conducted . RESULTS The lifetime incremental cost : utility ratios ( ICURs ) discounted at 3 % were $ 5321 per QALY for THA , $ 11,275 per QALY for TKA , $ 2307 per QALY for spinal decompression and $ 7153 per QALY for spinal decompression with fusion . The sensitivity analyses did not alter the ranking of the lifetime ICURs . CONCLUSION In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management , the lifetime ICUR for surgical treatment of Thromboprophylaxis with heparins after total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) is well established . The aim of this study was to compare low-molecular-weight heparin ( enoxaparin ) with partial thromboplastin time (PTT)-adjusted , unfractionated heparin ( heparin sodium ) . In a prospect i ve study of THA and TKA 246 patients , physical examination and compression and duplex ultrasound were performed 1 day before and 7 and 14 days after surgery . One hundred thirty patients received 40 mg enoxaparin subcutaneously once per day . One hundred sixteen patients received 5,000 IU heparin sodium subcutaneously 3 times daily . As the PTT did not reach 40 seconds , the heparin sodium dosage was increased to 7,500 IU 3 times daily . The overall thrombosis rate was 4 % ( n = 10 ) . In the enoxaparin group , the rate was 2.9 % of the 70 THAs and 10 % of the 60 TKAs . Thrombosis also occurred in the group that received heparin sodium : 1.8 % of the THAs and 1.7 % of the TKAs . For TKA , the difference between the 2 heparin groups was statistically significant . In the thromboprophylaxis of TKA , PTT-adjusted unfractionated heparins are superior to fixed doses of low-molecular-weight heparins We have prospect ively evaluated the efficacy of an individualized pre-operative blood saving protocol in elective total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) . The primary aim was to obtain a pre-operative haemoglobin ( Hb ) level of > or = 14 g dL(-1 ) . A reduction in requirements for allogeneic transfusion was considered the second aim . Several strategies are available for increasing pre-operative Hb levels and reducing red blood cell ( RBC ) transfusions following THA or TKA , but the success of these programmes depends on selecting the most appropriate treatment for each patient . Three hundred and five patients with an indication of elective THA or TKA were individually assigned to the following strategies according to Hb and ferritin levels and medical conditions : ( a ) no pre-operative intervention , ( b ) oral iron therapy , ( c ) intravenous ( i.v . ) iron therapy , ( d ) recombinant human erythropoietin alpha with i.v . iron and ( e ) pre-operative autologous donation ( PAD ) plus oral iron . Eighty-two percent of the patients reached a pre-operative Hb level of > or = 14 g dL(-1 ) compared with 62 % of patients with Hb levels of > or = 14 g dL(-1 ) at the baseline visit . Treatment with PAD showed a significant reduction in the pre-operative Hb levels . The rate of RBC transfusion was 18.8 % compared with 31.5 % of matched historic group ( P < 0.001 ) . In conclusion , all patients scheduled to undergo THA or TKA should be c and i date s for an individualized pre-operative blood salvage programme
Meta- analysis showed that high-dose systemic steroid ( dexamethasone > 0.1 mg/kg ) rather than low dose is effective to reduce postoperative nausea and vomiting and postoperative acute pain ( within 24 h ) .
In addition , systemic steroid is associated within faster functional rehabilitation and greater inflammation control .
On the other h and , systemic steroid is associated with a higher level of postoperative serum glucose on the operation day .
Conclusions Our study suggests that by providing lower incidence of postoperative nausea and vomiting and less postoperative acute pain , high-dose systemic steroid plays a critical role in rapid recovery to TKA and THA .
The preliminary results also show the superior possibility of systemic steroid in functional rehabilitation and inflammation control .
Background Perioperative systemic steroid administration for rapid recovery in total knee and hip arthroplasty ( TKA/THA ) is an important and controversial topic .
We conducted this systematic review and meta- analysis to evaluate the overall benefits and harms of perioperative systemic steroid in patients undergoing TKA and THA .