Health-related quality of life and appropriateness of knee or hip joint replacement. Associations between preoperative Oxford hip and knee scores and costs and quality of life of patients undergoing primary total joint replacement in the NHS England: an observational study Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. Impact of thromboprophylaxis guidelines on clinical outcomes following total hip and total knee replacement. Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression. Cement as a risk factor for deep-vein thrombosis. Comparison of cemented TKR, uncemented TKR and cemented THR. Effect of local anaesthetic infiltration on chronic postsurgical pain after total hip and knee replacement: the APEX randomised controlled trials Leisure time physical activity and the risk of hip or knee replacement due to primary osteoarthritis: a population based cohort study (The HUNT Study) Local anaesthetic wound infiltration in addition to standard anaesthetic regimen in total hip and knee replacement: long-term cost-effectiveness analyses alongside the APEX randomised controlled trials A phase II study of the oral factor Xa inhibitor LY517717 for the prevention of venous thromboembolism after hip or knee replacement. Patient expectations of arthroplasty of the hip and knee. Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography. Identifying orthopedic patients at high risk for venous thromboembolism despite thromboprophylaxis. Cost-effectiveness impact of rivaroxaban versus new and existing prophylaxis for the prevention of venous thromboembolism after total hip or knee replacement surgery in France, Italy and Spain. Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study. The effect of local anaesthetic wound infiltration on chronic pain after lower limb joint replacement: A protocol for a double-blind randomised controlled trial Venous thromboembolism prevention with fondaparinux 1.5 mg in renally impaired patients undergoing major orthopaedic surgery. A real-world, prospective, multicentre, cohort study. Is Obesity a Contraindication for Minimal Invasive Total Knee Replacement? A Prospective Randomized Control Trial Blood use in elective surgery: the Austrian benchmark study. Improving pain management after total joint replacement surgery. Effect of preparatory information prior to elective total hip replacement on psychological coping outcomes.
BACKGROUND We studied the association between explicit appropriateness criteria for total hip joint replacement ( THR ) and total knee replacement ( TKR )  with changes in health-related quality of life of patients undergoing these procedures . METHODS Prospect i ve observational study of 1576 consecutive patients with diagnoses of osteoarthritis on waiting lists to undergo THR or TKR . Explicit appropriateness criteria using the R AND appropriateness method were applied . Patients completed 2 question naires that measured health-related quality of life , the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) and the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , before the procedure and 6 months afterward . RESULTS Patients who were considered appropriate c and i date s for these procedures had greater improvements than those who were considered inappropriate c and i date s in all 3 WOMAC domains ( pain , functional limitation , and stiffness ; THR : 43.0 , 40.6 , and 40.4 vs 14.7 , 19.1 , and 15.9 ; TKR : 34.9 , 32.5 , and 30.2 vs 23.2 , 18.9 , and 17.1 ; P<.001 for all comparisons ) . Patients who underwent THR and were judged to be appropriate c and i date s had greater improvements in the physical function , role-physical , bodily pain , and social function domains of the SF-36 than those judged to be inappropriate c and i date s ( 34.4 , 35.1 , 33.1 , and 26.6 vs 19.6 , 9.2 , 5.7 , and 7.0 ; P = .04 , P = .03 , P < .001 , and P < .001 , respectively ) . Appropriate c and i date s for TKR demonstrated greater improvement in the social function domain of the SF-36 after the procedure than those deemed inappropriate c and i date s ( 19.9 vs 7.9 ; P = .004 ) but not in the other domains of functional status . CONCLUSIONS These results suggest a direct relationship between explicit appropriateness criteria and better health-related quality -of-life outcomes after THR and TKR surgery . Our results support the use of these criteria for clinical guidelines or evaluation purpose Objectives To assess how costs and quality of life ( measured by EuroQoL-5 Dimensions ( EQ-5D ) ) before and after total hip replacement ( THR ) and total knee replacement ( TKR ) vary with age , gender and preoperative Oxford hip score ( OHS ) and Oxford knee score ( OKS ) . Design Regression analyses using prospect ively collected data from clinical trials , cohort studies and administrative data bases . Setting UK secondary care . Participants Men and women undergoing primary THR or TKR . The Hospital Episode Statistics data linked to patient-reported outcome measures included 602 176 patients undergoing hip or knee replacement who were followed up for up to 6 years . The Knee Arthroplasty Trial included 2217 patients undergoing TKR who were followed up for 12 years . The Clinical Outcomes in Arthroplasty Study cohort included 806 patients undergoing THR and 484 patients undergoing TKR who were observed for 1 year . Outcome measures EQ-5D-3L quality of life before and after surgery , costs of primary arthroplasty , costs of revision arthroplasty and the costs of hospital readmissions and ambulatory costs in the year before and up to 12 years after joint replacement . Results Average postoperative utility for patients at the 5th percentile of the OHS/OKS distribution was 0.61/0.5 for THR/TKR and 0.89/0.85 for patients at the 95th percentile . The difference between postoperative and preoperative EQ-5D utility was highest for patients with preoperative OHS/OKS lower than 10 . However , postoperative EQ-5D utility was higher than preoperative utility for all patients with OHS≤46 and those with OKS≤44 . In contrast , costs were generally higher for patients with low preoperative OHS/OKS than those with high OHS/OKS . For example , costs of hospital readmissions within 12 months after primary THR/TKR were £ 740/£888 for patients at the 5th percentile compared with £ 314/£404 at the 95th percentile of the OHS/OKS distribution . Conclusions Our findings suggest that costs and quality of life associated with total joint replacement vary systematic ally with preoperative symptoms measured by OHS/OKS The aim of this study was to perform a cost-utility analysis of  total hip ( THR ) and knee replacement ( TKR ) .  Arthritis is a disabling condition that leads to long-term deterioration in quality of life . Total joint replacement , despite being one of the greatest advances in medicine of the modern era , has recently come under scrutiny . The National Health Service ( NHS ) has competing dem and s , and re source allocation is challenging in times of economic restraint . Patients who underwent THR ( n = 348 ) or TKR ( n = 323 ) between January and July 2010 in one Scottish region were entered into a prospect i ve arthroplasty data base . A health-utility score was derived from the EuroQol ( EQ-5D ) score pre-operatively and at one year , and was combined with individual life expectancy to derive the quality -adjusted life years ( QALYs ) gained . Two-way analysis of variance was used to compare QALYs gained between procedures , while controlling for baseline differences . The number of QALYs gained was higher after THR than after TKR ( 6.5 vs 4.0 years , p < 0.001 ) . The cost per QALY for THR was £ 1372 compared with £ 2101 for TKR . The predictors of an increase in QALYs gained were poorer health before surgery ( p < 0.001 ) and younger age ( p < 0.001 ) . General health ( EQ-5D VAS ) showed greater improvement after THR than after TKR ( p < 0.001 ) . This study provides up-to- date cost-effectiveness data for total joint replacement . THR and TKR are extremely effective both clinical ly and in terms of cost effectiveness , with costs that compare favourably to those of other medical interventions Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery . This prospect i ve study compared the outcome , complications , and mortality of total hip ( TKR ) and total knee replacement ( TKR )  in a prospect ively selected group of patients aged ≥ 80 years with that of a control group aged between 65 and 74 years . There were 171 and 495 THRs and 185 and 492 TKRs performed in the older and control groups , respectively . No significant difference was observed in the mean improvement of Oxford hip and knee scores between the groups at 12 months ( 0.98 , ( 95 % confidence interval ( CI ) -0.66 to 2.95 ) , p = 0.34 and 1.15 ( 95 % CI -0.65 to 2.94 ) , p = 0.16 , respectively ) . The control group had a significantly ( p = 0.02 and p = 0.04 , respectively ) greater improvement in the physical well being component of their SF-12 score , but the older group was more satisfied with their THR ( p = 0.047 ) . The older group had a longer hospital stay for both THR ( 5.9 versus 9.0 days , p < 0.0001 ) and TKR ( 6.2 versus 8.3 days , p < 0.0001 ) . The rates of post-operative complications and mortality were increased in the older group BACKGROUND The American College of Chest Physicians ( ACCP ) guidelines recommends thromboprophylaxis for total hip replacement ( THR ) and total knee replacement ( TKR ) patients . We examined alignment with ACCP thromboprophylaxis guidelines among THR/TKR patients , and compared symptomatic venous thromboembolism ( VTE ) , bleeding event rates and risk factors for VTE between patients receiving ACCP-recommended thromboprophylaxis ( ' ACCP ' ) and those who did not ( ' non-ACCP ' ) . METHODS This retrospective observational study used a large US health plan cl aims data base that was linked to an inpatient data base containing detailed inpatient medication use and a data base containing date -of-death information . Patients who had THR/TKR surgery between April 01 , 2004 and December 31 , 2006 were included . Comparisons of VTE and bleeding events between ACCP and non-ACCP patients were analyzed using chi-squared tests and multivariate logistic regression . RESULTS Of 3,497 linked patients , 1,395 ( 40 % ) received ACCP recommended thromboprophylaxis . Of the patients who received non-ACCP recommended prophylaxis the majority ( 81 % ) received shorter than the recommended minimum 10 day prophylaxis and 118 ( 5.6 % ) of patients received no prophylaxis . Overall , non-ACCP patients were almost twice as likely to experience an incident DVT ( 3.76 % versus 2.01 % , p=0.003 ) and more than eight times as likely to experience an incident PE ( 1.19 % versus 0.14 % , p=0.001 ) relative to ACCP patients ; there were no statistically significant difference in bleeding rates . Multivariate logistic regression indicated that the odds of a VTE event were significantly lower for ACCP patients ( DVT : OR=0.54 ; p=0.006 ; PE : OR=0.12 ; p=0.004 ) . CONCLUSIONS This study offers a unique perspective on ' real-world ' thromboprophylaxis patterns and associated outcomes in THR and TKR patients in the US . It suggests that only 40 % of THR/TKR patients receive ACCP-recommended thromboprophylaxis and that not receiving ACCP thromboprophylaxis is an independent risk factor for both DVT and PE After total hip ( THR ) or knee replacement ( TKR ) , there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin ( LMWH ) . In a prospect i ve , r and omised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR . We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings . Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression . In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6 % ( 40 % after TKR , 14 % after THR ) . This difference was significant ( p < 0.0001 ) . In the early post-operative phase after THR and TKR , combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings A total of 110 total knee replacements ( TKRs ) was r and omised to receive either a cemented or an uncemented prosthesis . Postoperative venography at five to seven days was used to compare the prevalence , site and size of deep-vein thrombosis ( DVT ) . We also compared the findings with those of postoperative venography in a group of patients with cemented total hip replacements ( THRs ) . The total prevalence of DVT was significantly greater after uncemented ( 81 % ) than after cemented TKR ( 55 % ) . Both knee groups had a significantly higher prevalence of DVT than in cemented hip replacements ( 32 % ) . We found no difference in the proportion with proximal DVT in the three groups ( 14 % , 15 % and 16 % ) . The median length of the thrombi was significantly greater after cemented ( 26.5 cm ) than after uncemented TKR ( 11 cm ) or after cemented THR ( 7 cm ) . This difference was mainly due to greater lengths of distal rather than proximal thrombi . We conclude that the use of cement may affect the formation of DVT after joint replacement , but does not appear to lead to an increased incidence Abstract Total hip replacement ( THR ) and total knee replacement ( TKR ) are usually effective at relieving pain ; however , 7 % to 23 % of patients experience chronic postsurgical pain . These trials aim ed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis . Between November 2009 and February 2012 , 322 patients listed for THR and 316 listed for TKR were recruited into a single-centre double-blind r and omised controlled trial . Participants were r and omly assigned ( 1:1 ) to receive local anaesthetic infiltration and st and ard care or st and ard care alone . Participants and outcomes assessors were masked to group allocation . The primary outcome was pain severity on the WOMAC Pain Scale at 12 months after surgery . Analyses were conducted using intention-to-treat and per- protocol approaches . In the hip trial , patients in the intervention group had significantly less pain at 12 months postoperative than patients in the st and ard care group ( differences in means : 4.74 ; 95 % confidence interval [ CI ] : 0.95 - 8.54 ; P = 0.015 ) , although the difference was not clinical ly significant . Post hoc analysis found that patients in the intervention group were more likely to have none to moderate pain than severe pain at 12 months than those in the st and ard care group ( odds ratio : 10.19 ; 95 % CI : 2.10 - 49.55 ; P = 0.004 ) . In the knee trial , there was no strong evidence that the intervention influenced pain severity at 12 months postoperative ( difference in means : 3.83 ; 95 % CI : −0.83 to 8.49 ; P = 0.107 ) . In conclusion , routine use of infiltration could be beneficial in improving long-term pain relief for some patients after THR Background The relationship between leisure time physical activity ( LPA ) and hip and knee OA and subsequent joint replacement has not yet been clearly defined . Some studies have found the risk of knee replacement ( TKR ) to increase with high levels of LPA , while others have found no overall relationship to either TKR or hip replacement ( THR ) . The aim was to investigate the association between LPA and the risk of severe end-stage OA  , defined as THR or TKR due to primary OA , in a large population -based cohort . Methods Participants in the Nord-Trøndelag Health Study ( HUNT ) were followed prospect ively to identify THR and TKR using the Norwegian Arthroplasty Register . Self-reported LPA was classified as inactive , low , moderate or high . The Cox proportional hazards model was used to calculate hazard ratios ( HRs ) according to levels of LPA with adjustments for confounding variables . Analyses were performed by age ( < 45 , 45–59 and ≥60 years ) and sex . Results A total of 66 964 participants ( mean age 46.8 years ( SD 16.3 ) were included in the analyses . We identified 1636 THRs and 1016 TKRs due to primary OA during 17.0 years ( median ) of follow-up . High LPA was significantly associated with THR for women < 45 years ( HR 1.78 , 95 % CI 1.08–2.94 ) and men between 45–59 years ( HR 1.53 , 95 % CI 1.10–2.13 ) at baseline . A significant trend was found only among women < 45 years at baseline ( p = 0.02 ) . We found that LPA was significantly associated with TKR for women only ( HR 1.45 , 95 % CI 1.03–2.04 ) . No measures of LPA were associated with TKR for men . Conclusion In this population -based study , high level of LPA was associated with increased risk of THR where a significant trend of LPA was seen among women < 45 years at baseline . For TKR , high LPA was associated with increased risk only in women . In contrast to previous studies , this study shows a possible association between high LPA and the risk of THR Background The Arthroplasty Pain Experience ( APEX ) studies are two r and omised controlled trials in primary total hip ( THR ) and total knee replacement ( TKR ) at a large UK orthopaedics centre . APEX investigated the effect of local anaesthetic wound infiltration ( LAI ) , administered before wound closure , in addition to st and ard analgesia , on pain severity at 12 months . This article reports results of the within-trial economic evaluations . Methods Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years ( QALYs ) and the primary clinical outcome , the WOMAC Pain score at 12-months follow-up . Re source use was collected from hospital records and patient-completed postal question naires , and valued using unit cost estimates from local NHS Trust finance department and national tariffs . Missing data were addressed using multiple imputation chained equations . Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes . If no arm was dominant ( i.e. , more effective and less expensive than the other ) , incremental cost-effectiveness ratios were estimated . The economic results were bootstrapped incremental net monetary benefit statistics ( INMB ) and cost-effectiveness acceptability curves . One-way deterministic sensitivity analyses explored any method ological uncertainty . Results In both the THR and TKR trials , LAI was the dominant treatment : cost-saving and more effective than st and ard care , in relation to QALYs and WOMAC Pain . Using the £ 20,000 per QALY threshold , in THR , the INMB was £ 1,125 ( 95 % BCI , £ 183 to £ 2,067 ) and the probability of being cost-effective was over 98 % . In TKR , the INMB was £ 264 ( 95 % BCI , −£710 to £ 1,238 ) , but there was only 62 % probability of being cost-effective . When considering an NHS perspective only , LAI was no longer dominant in THR , but still highly cost-effective , with an INMB of £ 961 ( 95 % BCI , £ 50 to £ 1,873 ) . Conclusions Administering LAI is a cost-effective treatment option in THR and TKR surgeries . The evidence , because of larger QALY gain , is stronger for THR . In TKR , there is more uncertainty around the economic result , and smaller QALY gains . Results , however , point to LAI being cheaper than st and ard analgesia , which includes a femoral nerve block . Trial registration IS RCT N96095682 , 29/04/2010 BACKGROUND LY517717 is an oral direct inhibitor of activated factor X that is currently under clinical development . OBJECTIVES The aims of this proof-of-concept study in patients undergoing total knee replacement ( TKR ) or total hip replacement ( THR ) were to determine whether LY517717 can safely reduce the risk of venous thromboembolism ( VTE ) and to identify at least one dose of LY517717 that is non-inferior to enoxaparin . METHODS In a double-blind , parallel-arm , dose-ranging study , patients undergoing TKR or THR were r and omly allocated to receive once-daily oral LY517717 ( 25 , 50 , 75 , 100 , 125 or 150 mg ) , started 6 - 8 h after wound closure , or s.c . enoxaparin , 40 mg , started in the evening before surgery . The primary efficacy endpoint was the composite of deep venous thrombosis ( DVT ) , detected by m and atory bilateral venography performed at the end of the study treatment ( between days 5 and 9 ) , and objective ly confirmed symptomatic DVT and /or pulmonary embolism ( PE ) , occurring during the treatment period . The combination of major and minor bleeding was the primary safety endpoint . RESULTS Five hundred and seven patients received at least one dose of LY517717 or enoxaparin ( safety population ) . Three hundred and ninety-one patients had evaluable bilateral venography or experienced a clinical DVT and /or PE ( primary efficacy population ) . LY517717 treatment result ed in a dose-dependent decrease in the incidence of thromboembolic events ( P = 0.0001 ) . The incidences of VTE with 100 , 125 , and 150 mg of LY517717 were 19 % , 19 % and 16 % , respectively , compared to 21 % with enoxaparin . The efficacies of 100-mg , 125-mg and 150-mg doses of LY517717 were non-inferior to that of enoxaparin according to prespecified criteria . Bleeding events were uncommon in both LY517717 and enoxaparin patients . CONCLUSIONS Doses of 100 , 125 and 150 mg of LY517717 are non-inferior to enoxaparin for the prevention of VTE after TKR or THR , and are associated with similar low rates of bleeding Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of  hip ( THR ) and knee replacement ( TKR ) . The aim of this prospect i ve cohort study was to examine the expectations of patients undergoing THR and TKR  , and to identify differences in expectations , predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures . During the study period , patients who underwent 346 THRs and 323 TKRs  completed an expectation question naire , Oxford score  and  Short-Form 12 ( SF-12 ) score pre-operatively . At one year post-operatively , the Oxford score , SF-12 , patient satisfaction and expectation fulfilment were assessed . Univariable and multivariable analysis were performed . Improvements in mobility and daytime pain were the most important expectations in both groups . Expectation level did not differ between THR and TKR . Poor Oxford score , younger age and male gender significantly predicted high pre-operative expectations ( p < 0.001 ) . The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome . THR better met the expectations identified as important by patients . TKR failed to meet expectations of kneeling , squatting and stair climbing . High fulfilment of expectation in both THR and TKR was significantly predicted by young age , greater improvements in Oxford score and high pre-operative mental health scores . The fulfilment of expectations was highly correlated with satisfaction Introduction : The incidence of venous thromboembolism ( VTE ) in Western population s undergoing major orthopaedic surgery without any thromboprophylaxis has been reported to range from 32 % to 88 % . There is however limited information on incidence of VTE in Indian patients and most of the Indian patients undergoing these surgeries do not receive any form of prophylaxis regardless of their risk profile . Methods : A prospect i ve study was performed on 147 patients undergoing major orthopaedic surgery for total knee replacement ( TKR ) , total hip replacement ( THR ) , and proximal femur fracture fixation ( PFF ) without any prophylaxis .  These patients were profiled for presence of the known risk factors responsible for development of VTE . A duplex ultrasound on both lower limbs was done 6 to 10 days after surgery . Twenty three patients underwent THR , 22 patients underwent TKR , and 102 underwent surgery for PFF . The patients were assessed clinical ly for any signs of deep venous thrombosis ( DVT ) and pulmonary embolism ( PE ) . A helical CT scan was done in case of suspicion of PE and a duplex ultrasound was done in case of clinical suspicion of DVT irrespective of the stage of study . Results : The overall incidence of VTE was 6.12 % and that of PE was 0.6 % . The risk factors that were found to be significantly responsible for development of VTE ( p < 0.05 ) were : immobility greater than 72 hours , malignancy , obesity , surgery lasting more than two hours . Conclusion : The study reconfirms the belief that DVT has a lower incidence in Indian patients as compared with other ethnic groups BACKGROUND The incidence of postsurgical venous thromboembolism is thought to be low in Asian ethnic population s. OBJECTIVE We studied the incidence of deep-vein thrombosis ( DVT ) in Asian patients undergoing major orthopedic surgery of the lower limbs . PATIENTS / METHODS We performed a prospect i ve epidemiological study in 19 centers across Asia ( China , Indonesia , South Korea , Malaysia , Philippines , Taiwan , and Thail and ) in patients undergoing elective total hip replacement ( THR ) , total knee replacement ( TKR ) or hip fracture surgery ( HFS ) without pharmacological thromboprophylaxis .  The primary endpoint was the rate of DVT of the lower limbs documented objective ly with bilateral ascending venography performed 6 - 10 days after surgery using a st and ardized technique and evaluated by a central adjudication committee unaware of local interpretation . RESULTS Overall , of 837 Asian patients screened for this survey , 407 ( 48.6 % , aged 20 - 99 years ) undergoing THR ( n = 175 ) , TKR ( n = 136 ) or HFS ( n = 96 ) were recruited in 19 centers . DVT was diagnosed in 121 of 295 evaluable patients [ 41.0 % , ( 95 % confidence interval ( CI ) : 35.4 - 46.7 ) ] . Proximal DVT was found in 30 patients [ 10.2 % ( 7.0 - 14.2 ) ] . Total DVT and proximal DVT rates were highest in TKR patients ( 58.1 % and 17.1 % , respectively ) , followed by HFS patients ( 42.0 % and 7.2 % , respectively ) , then THR patients ( 25.6 % and 5.8 % , respectively ) . DVT was more frequent in female patients aged at least 65 years . Pulmonary embolism was clinical ly suspected in 10 of 407 patients ( 2.5 % ) and objective ly confirmed in two ( 0.5 % ) . CONCLUSIONS The rate of venographic thrombosis in the absence of thromboprophylaxis after major joint surgery in Asian patients is similar to that previously reported in patients in Western countries OBJECTIVE To evaluate risk factors for venous thromboembolism ( VTE ) despite thromboprophylaxis in major orthopedic surgery patients at a tertiary care hospital . METHODS Charts from consecutive patients who underwent total hip replacement ( THR ) , total knee replacement ( TKR ) , or hip fracture surgery ( HFS ) [ hip pinning or hemiarthroplasty ] from August 1 , 1999 , to April 30 , 2000 , at a large Canadian teaching hospital were abstract ed using st and ardized case report forms . Data were collected on patient characteristics , surgical characteristics , and thromboprophylaxis regimen . Results of tests performed for suspected VTE were documented . Associations between characteristics of interest and objective ly confirmed VTE were examined in multivariate analysis . RESULTS Over the study period , 310 patients underwent major orthopedic surgery  and received st and ard thromboprophylaxis with either dalteparin or enoxaparin ( mean duration of prophylaxis , 7 days ) . Of these , 34 % underwent THR , 30 % underwent TKR , and 36 % underwent HFS . Of 83 suspected cases of VTE , 44 cases ( 7 proximal and 37 distal deep venous thrombosis [ DVT ] ) ; 14 % of study population ) were confirmed with objective testing . Multivariate analyses revealed that knee surgery ( odds ratio [ OR ] , 4.8 ; 95 % confidence interval [ CI ] , 2.3 to 10.1 ) and type of low molecular weight heparin ( LMWH ) [ enoxaparin ( more protective ) : OR , 0.39 ; 95 % CI , 0.20 to 0.80 ] independently predicted VTE . No patient characteristics ( including previous VTE , malignancy , hormonal therapy , postoperative complications ) were associated with VTE . CONCLUSION Despite st and ard thromboprophylaxis , symptomatic breakthrough VTE , primarily distal DVT , developed in 14 % of patients undergoing major orthopedic surgery . Factors that independently predicted VTE in our population were TKR surgery and type of LMWH . TKR patients may warrant more aggressive postoperative physiotherapy and ambulation and adjunctive prophylactic measures such as pneumatic compression . Due to the heterogeneity of different LMWH compounds , direct comparison of the effectiveness of enoxaparin with dalteparin for orthopedic prophylaxis in prospect i ve , r and omized trials seems warranted Venous thromboembolism ( VTE ) has a significant impact on healthcare costs but is largely preventable with anticoagulant prophylaxis using low-molecular-weight heparins ( LMWHs ) , such as enoxaparin or dalteparin . Rivaroxaban and dabigatran etexilate are two new oral anticoagulants ( NOACs ) both compared with enoxaparin in separate trials . A decision analytic model with a healthcare and national payer perspective over a five-year time horizon was used to evaluate the cost-effectiveness of the NOACs for VTE prophylaxis after total hip replacement ( THR ) or total knee replacement ( TKR ) in France , Italy and Spain .  Efficacy and safety data were obtained from r and omised controlled trials of rivaroxaban vs enoxaparin and an indirect statistical comparison for rivaroxaban vs dabigatran . Rivaroxaban demonstrated dominance across all comparisons , indications and countries . In THR , total per-patient costs were reduced by up to € 160 in the enoxaparin comparison and € 115 in the dabigatran comparison , respectively . In addition , quality -adjusted life-years ( QALYs ) were increased by up to 0.0011 and 0.0012 in each comparison , respectively . Similarly , total costs were reduced in TKR by up to € 137 and € 28 in the enoxaparin and dabigatran comparisons , respectively . The total number of QALYs was increased by up to 0.0014 in the enoxaparin comparison and 0.0005 in the dabigatran comparison . The results were driven by costs since the incremental benefits were minimal . Rivaroxaban use could result in substantial healthcare cost savings and improved quality of life . The results are applicable across three European countries with differing healthcare systems so , potentially , could be generalised to a much wider population OBJECTIVES To determine the effect of guided imagery ( GI ) on functional outcomes of total knee replacement ( TKR ) , explore psychological and neuroimmune mediators , and assess feasibility of study implementation . DESIGN Investigator-blinded , r and omized , placebo-controlled pilot study . SETTING S Hospital , surgeon 's office , participant 's home . PARTICIPANTS 82 persons undergoing TKR . INTERVENTIONS Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments . OUTCOME MEASURES Gait velocity and Western Ontario and McMaster Universities Arthritis Index ( WOMAC ) Function scale . RESULTS Outcomes for 58 participants ( 29 receiving GI and 29 controls ) were analyzed at 6 months after surgery . The most frequent reason for noncompletion was protocol -driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint ( n = 15 ) . With imaging ability as a moderator , gait velocity , but not WOMAC Function score , was significantly improved at 6 months in the GI group . Participants in the GI group , but not the control group , had lower WOMAC Pain scores at 3 weeks after surgery than at baseline . Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group . GI group participants had lower treatment adherence but greater treatment credibility than the control group . CONCLUSION R and omized controlled trials of GI in the TKR population are feasible , but inclusion /exclusion criteria influence attrition . Further studies are needed to elaborate this study 's findings , which suggest that guided imagery improves objective , but not patient-reported , outcomes of TKR . Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated . Further investigation into optimal content and dosing of GI is needed Background For the majority of patients with osteoarthritis ( OA ) , joint replacement is a successful intervention for relieving chronic joint pain . However , between 10 - 30 % of patients continue to experience chronic pain after joint replacement . Evidence suggests that a risk factor for chronic pain after joint replacement is the severity of acute post-operative pain . The aim of this r and omised controlled trial ( RCT ) is to determine if intra-operative local anaesthethic wound infiltration additional to a st and ard anaethesia regimen can reduce the severity of joint pain at 12-months after total knee replacement ( TKR ) and total hip replacement ( THR ) for OA . Methods 300 TKR patients and 300 THR patients are being recruited into this single-centre double-blind RCT . Participants are recruited before surgery and r and omised to either the st and ard care group or the intervention group . Participants and outcome assessors are blind to treatment allocation throughout the study . The intervention consists of an intra-operative local anaesthetic wound infiltration , consisting of 60 mls of 0.25 % bupivacaine with 1 in 200,000 adrenaline . Participants are assessed on the first 5 days post-operative , and then at 3-months , 6-months and 12-months . The primary outcome is the WOMAC Pain Scale , a vali date d measure of joint pain at 12-months . Secondary outcomes include pain severity during the in-patient stay , post-operative nausea and vomiting , satisfaction with pain relief , length of hospital stay , joint pain and disability , pain sensitivity , complications and cost-effectiveness . A nested qualitative study within the RCT will examine the acceptability and feasibility of the intervention for both patients and healthcare professionals . Discussion Large-scale RCTs assessing the effectiveness of a surgical intervention are uncommon , particulary in orthopaedics . The results from this trial will inform evidence -based recommendations for both short-term and long-term pain management after lower limb joint replacement . If a local anaesthetic wound infiltration is found to be an effective and cost-effective intervention , implementation into clinical practice could improve long-term pain outcomes for patients undergoing lower limb joint replacement . Trial registration Current Controlled Trials IS RCT Despite the need for effective and safe thromboprophylactic drugs for patients with renal impairment , clinical trial data on anticoagulant agents are limited in this population . The study aim was to assess in the real-world setting the use of the once-daily 1.5 mg reduced dosage regimen of fondaparinux available for this context . In this prospect i ve cohort study , patients with a creatinine clearance ( CrCl ) of 20 - 50 ml/minute , undergoing total hip ( THR ) or knee ( TKR ) replacement or hip fracture surgery ( HFS )  received fondaparinux thromboprophylaxis . Main clinical outcomes were bleeding ( major/ clinical ly relevant non-major ) , symptomatic venous thromboembolism ( VTE ) and death . Overall , 442 patients ( 353 women ; median age : 82 years ; 39.4 % in ASA class ≥3 ; mean ± SD CrCl : 39.0 ± 8.0 ml/minute ; 78 % with additional risk factors for bleeding ) , undergoing THR ( 43.7 % ) , TKR ( 27.6 % ) , or HFS ( 28.7 % )  received fondaparinux 1.5 mg for a mean ± SD duration of 16.0 ± 12.5 days . At postoperative day 10 , the rates ( 95 % confidence interval ) of major bleeding , clinical ly relevant bleeding and symptomatic VTE were 4.5 % ( 2.8 - 6.9 ) , 0.5 % ( 0.1 - 1.6 ) and 0.5 % ( 0.05 - 1.62 ) , respectively ; no fatal bleeding , bleeding into a critical organ , pulmonary embolism or proximal deep-vein thrombosis occurred . Corresponding rates at one month were 5.2 % , 0.7 % and 0.7 % . One-month mortality was 2.3 % ( 0.9 - 3.6 ) . This large clinical prospect i ve study provides for the first time , under conditions reflecting " real-world " routine clinical practice , data on the bleeding and VTE risks of thromboprophylaxis with fondaparinux 1.5 mg after major orthopaedic surgery in renally impaired patients . It shows that these patients constitute a very elderly and fragile population Background Although total knee replacement ( TKR ) has been proven a very successful treatment modality for the end-stage knee osteoarthritis ( OA ) in obese patients , the rehabilitation period often is long and painful . Minimal invasive surgery ( MIS ) has gained much attention in TKR promising fast and less painful recovery . However , little is known about the effectiveness of the technique in the obese adult population . Methods One hundred consecutive patients with body mass index ( BMI ) > 30 kg/m2 and tricompartmental knee OA were r and omly assigned to undergo either st and ard TKR ( 50 patients ) or MIS-TKR ( 50 patients ) . The patients were assessed clinical ly and radiologically before the procedure and at subsequent postoperative follow-up visits , until 2 years after the operation . Results Knee society function and pain scores were significantly higher in MIS group for 3 months following surgery . Patients after MIS had also lower levels of pain during hospitalization . Tourniquet time was on average 7 min longer during MIS-TKR ( p = 0.03 ) but operative time was almost equal in both groups ( p = 0.11 ) . No statistical significant difference was found between groups regarding the amount of blood loss ( p = 0.49 ) or incidence of allogeneic blood transfusion ( p = 0.27 ) . Active straight leg raising was achieved 2.2 days earlier , on average , after MIS-TKR ( p < 0.001 ) . No severe complications or residual coronal and sagittal imbalance were identified . Component alignment was in normal limits and similar in both groups . In MIS group , higher BMI did not have a negative predictive effect on knee pain and function . Conclusions MIS is a reliable and safe option in obese patients undergoing TKR regardless the level of BMI . It is associated with improved early clinical outcome without sacrificing radiographic positioning of the implants BACKGROUND Benchmarking transfusion activity may help to eliminate inappropriate use of blood products . The goal of this study was to measure and to compare the current transfusion  practice and to identify predictors of transfusion in public hospitals to develop strategies to optimize transfusion practice s. STUDY DESIGN AND METHODS This was a prospect i ve observational study in 18 r and omly selected public hospitals from April 2004 to February 2005 . Primary outcome measures were the amount of intra- and postoperative blood components transfused and intercenter variability of transfusion rate . Secondary outcome measures were prevalence of preoperative anemia , calculated perioperative blood loss , and lowest measured perioperative hemoglobin ( Hb ) level . RESULTS Adult patients undergoing primary unilateral total hip replacement ( THR , n = 1401 ) , primary unilateral knee replacement ( TKR , n = 1296 ) , hemicolectomy ( HECOC , n = 148 ) , and coronary artery bypass graft ( CABG ) surgery ( n = 777 ) were enrolled . Due to the small number , data of HECOC patients were not fully analyzed . In the remaining procedures , there was a large intercenter variability in the percentage of patients who received transfusions : THR 16 to 85 percent , TKR 12 to 87 percent , and CABG 37 to 63 percent . In the patients who received transfusions , the number of red blood cells ( RBC ) units transfused varied significantly . There was also a considerable intercenter variability in RBC loss . The prevalence of preoperative anemia was 19 percent and identical in both sexes . The incidence of preoperative anemia was three times higher in patients who received transfusions compared to those who did not . CONCLUSION This study demonstrates a high intercenter variability in RBC transfusions and RBC loss in st and ard surgical procedures . Whereas the variability in blood loss remains largely unexplained , the main predictors for allogeneic RBC transfusions are preoperative and nadir Hb and surgical RBC loss PURPOSE To test the effects of implementing evidence -based postoperative pain management content and strategies on patient , provider ( nurse and physician ) , and fiscal outcomes . SAMPLE 118 patients , 57 before and 61 after implementation , having total knee replacement ( TKR ) ( 54 % ) and total hip replacement ( THR ) ( 45 % ) , and 28 orthopaedic nurses . METHODS A research utilization approach with a pretest/posttest design was used . Independent variables ( interventions ) included evidence -based pain management content , education of care providers and patients , and system changes at the point of care . Dependent variables ( outcomes ) were patient perception of the postoperative pain experience , provider practice patterns , and length of stay ( LOS ) . FINDINGS The hypotheses of decreased provider use of meperidine and increased use of hydromorphone , i.v . route , pain plans of care , and nurse knowledge were supported . LOS was significantly reduced . The patient hypotheses decreased pain intensity and side effects and increased satisfaction and function were not supported . CONCLUSION Method ical implementation of evidence -based pain management information changed practice and fiscal outcomes . Improvement in the patient perception of pain management was more difficult to achieve The objective of this study was to evaluate the effects of preparatory information on psychological coping outcomes among total hip replacement ( THR ) patients . A quasi-experimental design within an ethnographic clinical context was used . Eighty-two healthy individuals , scheduled for elective THR were recruited for the study and nonr and om selection techniques were used . The subjects in the experimental group were given procedural , sensory and coping information relating to the whole surgical procedure of a THR . In addition , written information was given to support the verbal information . Subjects in the control group received only the advice and support that would routinely be given to THR patients by ward , medical and nursing staff . The main outcomes were measured using st and ard question naires , Hospital Anxiety and Depression Scale ( HADS ) measuring anxiety and depression , Rosenburg Self-Esteem Scale measuring self-esteem , and Health Illness Question naire measuring sense of control . Lastly , a Linear Analogue Coping Scale was developed and applied to assess a subject 's personal perception of coping with a THR . Providing information had positive effects on the psychological coping outcomes measured . Subjects in the experimental group had significantly less anxiety and depression with a high self-esteem and sense of control . The Linear Analogue Coping Scale demonstrated a strong correlation between how subjects believed they were coping and that measured using the st and ard question naires . The study concluded that preparatory information of various types and in different forms appears to have positive effects on psychological coping outcomes for THR patients , which may have influenced postoperative recovery
Intake of a carbohydrate-containing fluid is reported to improve insulin-like growth factor levels , reduce hunger , nausea , and length of stay , and attenuate the decrease in whole-body insulin sensitivity and endogenous glucose release .
Amino acid supplementation is reported to reduce muscle atrophy and accelerate return of functional mobility .
There is limited evidence for nutritional supplementation in THR and TKR pathways ; however , the low risk profile and potential benefits to adjunctive treatment methods , such as exercise programs , suggest nutritional supplements may have a role .
Optimizing nutritional status pre-operatively may help manage the surgical stress response , with a particular benefit for undernourished , frail , or elderly individuals
Nutritional supplements can influence outcomes for individuals undergoing major surgery , particularly in older persons whose functional reserve is limited .
Accelerating recovery from total hip replacement ( THR ) and total knee replacement ( TKR ) may offer significant benefits .
Therefore , we explored the role of nutritional supplements in improving recovery following THR and TKR .