Primary Hip and Knee Arthroplasty at District Level Is Safe and May Reduce the Burden on Tertiary Care in a Low-income Setting

doi:10.21203/rs.3.rs-1506574/v1

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Primary Hip and Knee Arthroplasty at District Level Is Safe and May Reduce the Burden on Tertiary Care in a Low-income Setting

https://doi.org/10.21203/rs.3.rs-1506574/v1

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Background: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level and its potential to decrease waiting list burden in a low-income setting.

Methods: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at Mitchell’s Plain Hospital (MPH), a district hospital and Groote Schuur Hospital (GSH), a tertiary academic hospital in Cape Town, South Africa between 1^st January 2015 and 31^st December 2018. Patient demographics, hospital stay, surgery related readmissions, reoperations, post-operative complications, and mortality were compared between cohorts.

Results: 795 primary arthroplasty surgeries were performed at tertiary hospital (TH) level and 228 at district hospital (DH) level. The average hospital stay was 5.2±2.0 days at DH level and 7.6±7.1 days for TH (p<0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p<0.05). Reoperation rate of 1 in every 100 patients at district and 8.3 in every 100 patients at tertiary level (p<0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p>0.05). Periprosthetic joint infection (PJI) rate was 0,43% at DH and 2,26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level.

Conclusions: Hip and knee Arthroplasty at district level is safe and may reduce the burden on tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures.

Level of Evidence: Level III Retrospective cohort study

Hip and knee replacement is amongst the most successful^1–4 and cost effective surgical interventions to increase quality-adjusted life expectancy (QALE).^{3, 5, 6} Despite this, even in developed nations a vast discrepancy exists between demand for surgery and service provision, resulting in lengthy waiting times. ^7–9

This is perpetuated by depleted resources and an increasingly aging population,¹⁰ especially in low-middle income countries,^{11, 12} and furthermore exacerbated by the covid-19 pandemic.

These economic barriers are also associated with a different comorbidity profile (i.e. HIV infection) compared to high income settings which could adversely affect outcomes.¹³

A reasonable waiting time for orthopaedic elective surgery has previously been established at 10 weeks,¹⁴ although more than half of the patients experience further deterioration during this waiting period.⁹ Prolonged waiting times result in an increased cost burden as patients require additional analgesic medication and clinic visits with associated travel costs. This is often compounded by loss of work, especially in patients of low-income households.¹⁵ In Southern Africa, arthroplasty is practiced both in state-funded tertiary centers and private hospitals. With limited access to private health care, state-funded hospitals are overburdened with waiting times of more than 12 months for arthroplasty. ⁷

An expansion of arthroplasty services at a tertiary level may seem the obvious solution. But strategies to restrict arthroplasty to high-volume tertiary centres will notably affect older, poorer, less-educated, and rural patients,¹⁶ widening existing economic disparities in arthroplasty surgery utilisation.¹⁶ This has triggered arthroplasty surgery at more levels in the healthcare system including level 1 (district hospitals with limited specialist services) and level 2 (regional hospitals with at least two specialist services)¹⁷

When compared to tertiary care facilities, these first and second level hospitals may encounter increased challenges due to budget constraints and fewer qualified orthopaedic surgeons. Additionally, a higher proportion of presenting trauma-related surgical cases may affect resources for elective surgery. The resulting reduced volume in arthroplasty has been associated with inferior outcomes and a higher rate of complications. ^{16, 18, 19} Yet, to our knowledge no large study exists on the safety and complication rates for arthroplasty patients in district level facilities in a low-income setting. ^{13, 20}

Our aim was therefore to map the complication profile of arthroplasty surgery in a district level hospital and compare it and its surgical volume to a tertiary care facility.

This is a retrospective comparative cohort study. Consecutive patients who underwent primary arthroplasty at an urban district hospital (DH) in Southern Africa from 2015 to 2018 were compared to those from a tertiary hospital (TH) in the same city. This DH is a direct referring facility to the TH, with a 893 bed service in the TH and 230 beds in the DH (of which only 18 are allocated orthopaedics beds). Both hospitals are state funded facilities. The DH services a population of approximately 1.2 million people with an average unemployment rate approximating 24.2%.²¹ The DH arthroplasty surgeries were evenly distributed among three surgeons, two generalist orthopaedic surgeons and one sessional fellowship trained orthopaedic surgeon. None of these three surgeons were performing surgeries at the TH. They provided mostly an orthopaedic trauma service with a limited hip and knee arthroplasty service. They shared an average of 13 years of arthroplasty experience between them. The district cohort consists of patients from a lower socioeconomic background, residing in HIV and TB endemic area, with a life expectancy averaging 54 years.²² The TH has a dedicated arthroplasty unit with surgical team comprising two fellowship trained arthroplasty surgeons with an average of 10 years of arthroplasty experience (co-authors), and rotating trainee orthopaedic registrars. The registrars may perform certain surgeries but always under the direct supervision of the consultant. The primary author has worked at both DH and TH as trainee. All authors are part of the TH research unit.

Pre-operative American Society of Anaesthesiologists’ (ASA) scores were used as a simple guide to anaesthetic risk profile of the two cohorts.²³ Only patients with an ASA of I or II were selected for surgery at DH. The TH caters for all ASA grades because of availability of intensive care unit and more bed capacity.

The arthroplasty theatre setup were equivalent in both hospitals, but laminar flow was only available in the TH operating rooms. Similar clinical pathways for arthroplasty surgery were used in both hospitals including antiseptic skin preparation, sterile surgical site draping and antibiotic prophylaxis as recommended by the NICE guidelines.^{24, 25 26, 27} Patients received one dose of first-generation Cephalosporin antibiotic; or Clindamycin for those with penicillin allergy; prior to skin incision and 3 doses postoperatively. Surgical approaches included medial parapatellar knee approach and either a posterior or anterolateral hip approach. All total knee implants were cemented, all total hip implants were uncemented. Wound closure was with sutures and local anaesthetic infiltration.^{28, 29} Protocol included graduated compression stockings, low molecular weight heparin (clexane) and physiotherapy commencing on day one post-surgery²⁹. On discharge DH patients were started on low-dose aspirin for one month if no contraindications. TH patients did not receive aspirin. Patients were reviewed in the clinic at 2 weeks post discharge for removal of stitches, then at 6 weeks, 3 months, 6 months, 1 year and 2 years at which time they were discharged from the service if there were no complications. Discharged patients had easy access back into the service should the need arise.

Ethical approval was obtained from the Institutional Review Board (831/2019) prior to data collection. The arthroplasty service at the DH started in 2015 and therefore, all primary elective total knee and total hip replacement surgeries performed from 1 Jan 2015 to 31 Dec 2018 were included. Consecutive primary arthroplasty cases at the tertiary facility for the same period formed the comparative cohort. Patients undergoing arthroplasty for trauma, or oncological conditions, as well as patients with missing or incomplete folders were excluded. (see Fig. 1)

Demographic data such as age and gender along with clinical information, such as HIV status, American Society of Anaesthesiologists (ASA) physical status classification²³, pathology, type of procedure, hospital length of stay, and post-operative complications were recorded.

Complications were categorized into primary, secondary, tertiary, and quaternary level by the first author based on the relative outcome importance with regards subsequent resources or skills required for management. Then in a de-escalating fashion less severe complications recorded at the subsequent levels. Continuous data was compared using Mann-Whitney U test. The dependence of categorical data on the hospital was analysed using a chi-squared test method. The statistical tests were performed in IBM SPSS v.27 (IBM, Armonk, NY, USA). Statistical significance was defined as p < 0.05. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines were used to report the results.³⁰

Figure 1

During the study period, 795 tertiary level and 228 district level cases were included. 29.5% patients in the TH were male, compared to 27.4% at the DH (p = 0.53) (see Table 1)

At district level, a higher portion of ASA II patients (74.3% vs 64.1%) received surgery, whereas at the TH more ASA level III patients (23.4% vs 10.9%) were operated (p = 0.0002). A higher portion of HIV positive patients were operated in the district level hospital (12.2% vs 3.4%, p = 0.000002) although in most cases the HIV status was unknown.

Table 1

Patient Demographics
Characteristic		DH (n = 228)	TH (n = 795)
Average age		59.7 ± 10.9	60.1 ± 14.0	p = 0.17
Gender
	Female	72.6%	70.5%	p = 0.53
	Male	27.4%	29.5%
HIV Status	Positive	12.2%	3.4%	p = 0.000002
	Negative	23.5%	16.0%
	Unknown	80.6%	64.3%
American Society of Anaesthesiologists (ASA) physical status classification ²³
	I	14.8%	12.3%
	II	74.3%	62.8%
	III	10.9%	24.4%
	IV	0.0%	0.5%

Primary Unilateral TKR was the most commonly performed surgery for both hospitals, accounting for 48.8% at tertiary level and 52.7% in district level (p = 0.001). The bilateral surgeries accounted for < 5% of the total surgeries. (see Fig. 2)

Figure 2

Primary osteoarthritis (OA) was the most common indication for arthroplasty surgery (77.6% in district level and 69.9% at tertiary level). This was followed by avascular necrosis (AVN) (13.6% and 10.7% in district and tertiary levels respectively) and post traumatic OA or AVN (3.1% vs 2.3%) p = 0.05. At tertiary level 9.81% of arthroplasty surgery was performed for rheumatoid arthritis (RA) while there were no cases of RA at district level. The remaining pathology/aetiology accounted for < 1% of surgeries. (See Fig. 3)

Figure 3

Hospital stays for tertiary patients were longer than the district patients (7.6 ± 7.1 days vs 5.2 ± 2.0 days, p = 0.0001).

Tertiary Arthroplasty had 38.1% adverse events and district level had 32.6% (p = 0.01). Overall, physiological and mechanical complications predominated (10.8%) followed by non-orthopaedic related ward concerns (for example pressure sores, dizziness, confusion, glucose fluctuations, angina, constipation etc.) (4.8%) and wound related complications (3.6%). In the TH 26 (3.27%) patients received blood transfusion compared to 3 (1.31%) at the DH. (see Fig. 4) The follow up rate at post-operative week 6 was similar at both DH and TH level (99% of patients) but there were disparities at subsequent follow up visits.

Table 2

Rate of post-operative follow up at DH and TH level
Post-operative period	6 weeks	3 months	6 months	1 year	2 years
TH	99.05%	93.37%	88.06%	79.54%	24.43%
DH	99.46%	88.29%	76.59%	59.57%	18%

The readmission rate at tertiary level was 4 in every 100 patients operated whereas at the district level the readmission rate was 1 in every 100 patients (p = 0.04). Reoperation rate of 1 in every 100 patients at district and 8.3 in every 100 patients at tertiary level (p = 0.04). Of the cases that required a second theatre trip at TH, 4.1% had revision arthroplasty and 4.2% for reasons other than revision; for instance; closed reduction of dislocated hip in theatre or manipulation under anaesthesia for stiff knee. Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p = 0.76).

Table 3

Comparison of Orthopaedic Outcomes
Main Orthopaedic Outcome Measures		DH (n = 228)	TH (n = 795)
Revision Arthroplasty:		1.0% (3)	4.1% (33)
Reoperation not for revision		0	4.2% (34)
Dislocations		0	0.6% (5)
	Multiple dislocations requiring revision	0	0.4% (3)
PJI		0.87% (2)	1.0% (8)
Superficial Infection		2.63% (6)	1.76% (14)
Superficial wound problem other than infection		10.5% (24)	1.13% (9)
Neurological Complications		2.6% (6)	1.8% (14)
	Resolved	0.9% (2)	1.2% (10)
	Persistent	0.9% (2)	0.4 (3)
	Unknown	0.9% (2)	0.1% (1)
Haemoglobin (g/dl)	Pre-operative Hb	13.0 ± 1.4 g/dl	12.8 ± 1.7 g/dl
	Post-operative Hb	11.6 ± 1.7 g/dl	11.2 ± 1.8 g/dl	p = 0.02
	Average change in Hb	1.41	1.66
Blood Transfusion		1.3% (3)	3.3% (26)
Peri-Prosthetic Fracture		0.9% (2)	1.4% (11)
Heterotrophic Ossification		0.9% (2)	1.8% (14)

Table 4

Comparison of Non-Orthopaedic Outcomes
Main Non-Orthopaedic Outcome Measures			DH (n = 228)	TH (n = 795)
Average Hospital Stay			5.2 ± 2.0 days	7.6 ± 7.1 days	p = 0.0001
		Knee	5.44	7.17
		Hip	4.80	6.75
Readmissions < 3mth postoperative			1.7% (4)	4.4% (35)	p = 0.04
Peri-operative Death			0.4% (1)	0.6% (6)	P = 0.76
Other infections e.g. UTI, LRTI*			0.9% (2)	1.9% (15)
Thromboembolic event			1.7% (4)	1.0% (8)
	DVT		0.9% (2)	0.1% (1)
	PE		0.4% (1)	0.6% (5)
	CVA		0.4% (1)	0.2% (2)
Anaesthetic Related Complications			0.4% (1)	2.5% (20)

*UTI – Urinary Tract Infection; **LRTI – Lower Respiratory Infection

DVT – Deep Vein Thrombosis; PE – Pulmonary Embolis; CVA – cerebrovascular accident

Figure 5

Table 5

Other Physiological/ Mechanical Complications Recorded
Other Physiological/ Mechanical Complications	DH (n = 228)	TH (n = 795)
Leg Length Discrepancy (THR)	4.4% (10)	3.6% (29)
Stiffness/ decreased ROM* (TKR)	2.6% (6)	3.3% (26)
Fixed Flexion Deformity (THR)	1.0% (3)	1.4% (11)
Patella Pathology (Mal-tracking/ Creps)	0.9% (2)	1.4% (11)
Persistent pain > 3mths (TKR)	0.4% (1)	2.1% (17)
Instability (TKR)	0.0% (0)	1.0% (8)

*ROM – Range of Motion

During the study period, the DH was able to process 22.3% of primary arthroplasty cases – this means that 228 patients received their arthroplasty at the DH; these patients would have been on the TH waiting list if the DH offered no arthroplasty service.

Our findings show that hip and knee arthroplasty in our DH had a low complication rate, comparable to our TH, but also to other centres from high-income countries (HIC). ^31–33,⁴¹

A recent 10-week multicentred prospective observational study have also shown that arthroplasty at district hospitals and Tertiary hospitals in South Africa had comparable peri-operative morbidity results as seen in our study. ³⁴

The average length of stay at the TH (7.6 ± 7.1 days) was longer than at the DH (5.2 ± 2.0 days) with a p value less than 0.05. This is likely due to the fact that the TH catered for a higher proportion of patients with multiple co-morbidities and higher ASA grade, requiring multidisciplinary co-management and additional medical support.

In our study the Mortality rate did not differ significantly between the two hospitals (DH 0.4% vs TH 0.6%; p > 0.05) despite the differences in patients ASA grades in the 2 cohorts. This is also comparable to international reports from HIC. The one-year mortality rates in the National Joint Registry for England and Wales (NJR) were 10.8 and 8.9 per 1,000 patient-years after hip and knee arthroplasty, respectively. ^31–33 The cause of death at district hospital was attributed to a thromboembolic event more than 2 weeks after surgery and to perioperative cardiorespiratory complications in patients with ASA grade III and IV at TH. Although previous studies indicated the risk of mortality following surgery in patients across Africa is twice as high as the global average, this was not reflected in our study. ³⁵

Our study showed an average blood loss of 1.41g/dL and 1.66 g/dL for DH and TH respectively. This is consistent with the reported average decline in haemoglobin of 2.35 g/dL ± 1.14 and 2.29 g/dL ± 1.16 for THA and TKA.³⁶ In our TH, 26 (3.27%) patients received blood transfusion compared to 3 (1.31%) at the DH. This finding again may be a reflection of more complex cases (inflammatory arthropathies) being done at TH level with longer surgical time and possibly higher transfusion requirements.

The readmission rate of the TH was 4.40%, which was less than for the DH (1.75%), while still being within a range which is acceptable and reported in other centres³⁷. Reasons for re-admission varied from infection, knee stiffness, wound-related problems, or cardiovascular complications. There were 3 TKR (1.04%) revision surgeries from district level. Reasons for revisions included aseptic loosening, early PJI and a polyethylene insert dislodgement.

At tertiary level 33 (4.1%) patients required revision surgery. The most common indication for revision surgery was PJI (see Fig. 5). The higher revision rate from the TH could be the result of more complex pathology as well as higher ASA grade of patients treated at the TH.

There were 11 (1.38%) peri-prosthetic fractures recorded in the tertiary group, 4 (0.50%) occurred intra-operatively, all during THR (2 femur and 2 acetabular fractures). The district cohort had 2 (0.87%) peri-prosthetic fractures, both intra-operative tibial fractures during TKR. Our incidence of intraoperative periprosthetic fractures is close to the one reported in the analysis of International Registry data (0.8%) by Pivec et al.³⁸ There were no dislocations recorded at district level, 5 (0.62%) at tertiary level. This falls within the acceptable range of 2–3%.³⁹ The rates of thromboembolic events recorded at TH and DH (1.01% and 1.75% respectively) were similar to those reported in the literature.^38,39 (see Table 4) One thromboembolic event in each hospital resulted in death.

Leg length discrepancy after a THA is one of the major cause of patient dissatisfaction as demonstrated by Fujimaki et al.⁴⁰ Both hospitals showed analogous percentages of LLD; 3.65% (29) vs 4.38% (10) in tertiary and district level respectively. (see Fig. 3) However, a limitation of this study is that the change in leg length was not measured quantitatively but was rather a qualitative observation by the treating surgeons.

Overall tertiary and district level surgery had similar rates of physiological or mechanical concerns (11 vs 10%) (see Table 5), although many of these variables share the same concern as for LLD and were not measured comparisons.

The strength of this study is that it documents that an experienced surgeon using well accepted standards and techniques can perform TJA safely in a DH given careful patient selection. However, we must acknowledge its shortcomings, in that the study was conducted in a single district center with a relatively small sample size, and therefore results may not be generalisable or extrapolated to other district centers.

Only two state-funded facilities with a large discrepancy in the cohort sizes were assessed. Limited by the date of commencement of arthroplasty at the DH; the TH cohort has more than three times the number of patients. An important dispersion is generated, which makes it difficult to obtain statistically significant values. There was also no matching of cohorts to control for potential cofounders such as the discrepancy in comorbidity profile of patients. Nevertheless, we can see that low risk patients can safely have THR and TKR in the district setting provided the surgical methodology is up to the same standards as the TH. Another limitation is a relatively high loss to follow up; in low-income setting follow-up is often challenging and highlights the distances travelled by patients to access arthroplasty services.²⁰

This study shows that primary elective hip and knee arthroplasty can be safely performed at a district level of care in a southern African setting. The morbidity and complication profile at the district level was similar to that seen at tertiary level of care and that reported in the literature. Arthroplasty practice at more levels of care will help decongest waiting lists at Tertiary hospitals in our setting. Standard selection criteria and operating theatre protocols must be followed to optimise outcomes. Future studies should examine the capacity of the district facilities and how arthroplasty services could be optimised and upscaled to further aid southern African tertiary hospitals in reducing arthroplasty waiting times.

Consent for publication

Consent for publication is granted by all authors

Competing Interests

All authors declare no competing interests

Funding

No funding has been attained for this study

Authors' contributions

KL was the project administrator and involved in the data curation, analysis, and wrote the main manuscript. NK was responsible for conceptualisation, methodology and planning as well as supervision of the project. RD was responsible for data editing as well as formal analysis. MN and MH responsible for validation. All authors were involved in review and editing of the manuscript.

Kakar PN, Roy PM, Pant V, Das J. Anesthesia for joint replacement surgery: Issues with coexisting diseases. Journal of anaesthesiology, clinical pharmacology. Jul-Sep 2011;27(3):315–322. doi:10.4103/0970-9185.83673
Tsaras G, Osmon DR, Mabry T, et al. Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, olmsted county, Minnesota, 1969–2007. Infect Control Hosp Epidemiol. 2012 /12//2012;33(12):1207–1212. doi:10.1086/668421
Lisenda L, Mokete L, Kingsley N, Yp G, Lukhele M. Development of a Lower Limb Arthroplasty Service in a Developing Country: Lessons learned after the first 100 cases (joints). vol 82. 2016:2016.
Mulcahy H, Chew FS. Current Concepts in Knee Replacement: Complications. American Journal of Roentgenology. 2014/01/01 2013;202(1):W76-W86. doi:10.2214/AJR.13.11308
Norman-Taylor FH, Palmer CR, Villar RN. Quality-of-life improvement compared after hip and knee replacement. J Bone Joint Surg Br. Jan 1996;78(1):74–7.
Laupacis A, Rn B, Rorabeck C, et al. The Effect of Elective Total Hip Replacement Upon Health-Related Quality of Life. vol 75. 1993:1619-26.
Kavalieratos T, Nortje M, Dunn RN. Hip and knee arthroplasty waiting list – how accurate and fair? vol 107. 2017. 2017.
Pulido L, Parvizi J, Macgibeny M, et al. In Hospital Complications After Total Joint Arthroplasty. The Journal of Arthroplasty. 2008/ 09/01
Ackerman IN, Bennell KL, Osborne RH. Decline in Health-Related Quality of Life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study. BMC Musculoskeletal Disorders. 2011;12:108–108. doi:10.1186/1471-2474-12-108
Africa DoSS. Protecting South Africa's Elderly. STATS SA; 2020. 9 July 2020. 2021. http://www.statssa.gov.za/?p=13445
Dunn R. Musculoskeletal burden of disease: do we have any idea? SA Orthopaedic Journal. 2012;11:20–22.
/ 2008;23(6, Supplement):139–145. doi:https://doi.org/10.1016/j.arth.2008.05.011
Harris B, Goudge J, Ataguba JE, et al. Inequities in access to health care in South Africa. Journal of Public Health Policy. 2011;32:S102-S123.
Graham SM, Howard N, Moffat C, Lubega N, Mkandawire N, Harrison WJ. Total Hip Arthroplasty in a Low-Income Country: Ten-Year Outcomes from the National Joint Registry of the Malawi Orthopaedic Association. JB & JS open access. 2019;4(4):e0027.1-5. doi:10.2106/JBJS.OA.19.00027
Esmail N WW. Waiting Your Turn: Hospital Waiting Lists in Canada. Critical Issues Bulletin. 21 Oct 2003. The Fraser Institute;13th Edition. https://www.fraserinstitute.org/studies/waiting-your-turn-hospital-waiting-lists-in-canada-13th-edition
Bumpass DB, Nunley RM. Assessing the value of a total joint replacement. Current reviews in musculoskeletal medicine. 2012;5(4):274–282. doi:10.1007/s12178-012-9139-6
Stewart GD, Stewart PC, Nott ML, Long G. Total joint replacement surgery in a rural centre. Australian Journal of Rural Health. 2006;14(6):253–257. doi:doi:10.1111/j.1440-1584.2006.00825.x
Health Do. Hospital Classifications, Schedules and Codes. 01/09/2018, Updated 30/05/2018. https://www.westerncape.gov.za/general-publication/western-cape-government-hospital-tariffs-overview?toc_page=4
Schroer WC, Calvert GT, Diesfeld PJ, Reedy ME, LeMarr AR. Effects of Increased Surgical Volume on Total Knee Arthroplasty Complications. The Journal of Arthroplasty. 2008/09/01/ 2008;23(6, Supplement):61–67. doi:https://doi.org/10.1016/j.arth.2008.03.013
Dossche L, Noyez JF, Ouedraogo W, Kalmogho E. Establishment of a hip replacement project in a district hospital in Burkina Faso: analysis of technical problems and peri-operative complications. Bone Joint J. Feb 2014;96-b(2):177 – 80. doi:10.1302/0301-620x.96b2.31304
Graham SM, Howard N, Moffat C, Lubega N, Mkandawire N, Harrison WJ. Total Hip Arthroplasty in a Low-Income Country: Ten-Year Outcomes from the National Joint Registry of the Malawi Orthopaedic Association. JB & JS open access. Oct-Dec 2019;4(4)doi:10.2106/jbjs.oa.19.00027
Department of Health WCG. Mitchells Plain CHC. Updated 17 April 2018. https://www.westerncape.gov.za/dept/health/documents/public_info/M/39054?toc_page=1
O'Neill A. Life expectancy (from birth) in South Africa from 1870 to 2020. 20 August 2020. Accessed 16 August 2021. https://www.statista.com/statistics/1072248/life-expectancy-south-africa-historical/
Anesthesiologists ASo. ASA Physical Status Classification System. ASA House of Delegates/Executive Committee; October 15, 2014. October 23, 2019. Accessed 08/11/2020. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
Excellence NIfHaC. Surgical site infections: prevention and treatment. NICE guideline [NG125]. 11 April 2019 15/09/2021, https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-prevention-and-treatment-pdf-66141660564421
Foni NO, Costa LAV, Paião ID, et al. Clinical pathway improves medical practice in total knee arthroplasty. PLoS One. 2020;15(5):e0232881-e0232881. doi:10.1371/journal.pone.0232881
Walter F, Bass N, Bock G, Markel D. Success of Clinical Pathways for Total Joint Arthroplasty in a Community Hospital. Clinical orthopaedics and related research. 05/01 2007;457:133–7. doi:10.1097/01.blo.0000246567.88585.0a
Štrbac S, Rakic S, Vujic-Aleksic V, Skrbic R. The role of clinical pathways on healthcare quality improvement in hospitals for patient undergoing total hip replacement. Scripta Medica. 01/01 2020;51:87–92. doi:10.5937/scriptamed51-26870
Surgeons AAoO. Surgical Management of the Knee Evidence-Based Clinical Practice Guideline. September 4, 2015. https://www.aaos.org/globalassets/quality-and-practice-resources/surgical-management-knee/smoak-cpg_4.22.2016.pdf
Excellence NIfHaC. Joint replacement (primary): hip, knee and shoulder. NICE guideline [NG157]. National Guideline Centre, hosted by the Royal College of Physicians. 04 June 2020. 15/09/2021, https://www.nice.org.uk/guidance/ng157/resources/joint-replacement-primary-hip-knee-and-shoulder-pdf-66141845322181
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet (London, England). Oct 20 2007;370(9596):1453–7. doi:10.1016/s0140-6736(07)61602-x
Berstock JR, Beswick AD, Lenguerrand E, Whitehouse MR, Blom AW. Mortality after total hip replacement surgery: A systematic review. Bone Joint Res. Jun 2014;3(6):175–82. doi:10.1302/2046-3758.36.2000239
Berstock JR, Beswick AD, López-López JA, Whitehouse MR, Blom AW. Mortality After Total Knee Arthroplasty: A Systematic Review of Incidence, Temporal Trends, and Risk Factors. The Journal of bone and joint surgery American volume. Jun 20 2018;100(12):1064–1070. doi:10.2106/jbjs.17.00249
Trela-Larsen L, Kroken G, Bartz-Johannessen C, et al. Personalized estimation of one-year mortality risk after elective hip or knee arthroplasty for osteoarthritis. Bone & Joint Research. 2020;9(11):808–820. doi:10.1302/2046-3758.911.bjr-2020-0343.r1
Plenge U, Parker R, Davids S, et al. Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study. BMC Musculoskeletal Disorders. 2020/11/05 2020;21(1):721. doi:10.1186/s12891-020-03752-x
Biccard BM, du Toit L, Lesosky M, et al. Enhanced postoperative surveillance versus standard of care to reduce mortality among adult surgical patients in Africa (ASOS-2): a cluster-randomised controlled trial. The Lancet Global Health. 2021/08/19/ 2021;doi:https://doi.org/10.1016/S2214-109X(21)00291-6
Lindman IS, Carlsson LV. Extremely Low Transfusion Rates: Contemporary Primary Total Hip and Knee Arthroplasties. J Arthroplasty. Jan 2018;33(1):51–54. doi:10.1016/j.arth.2017.07.034
Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. The Journal of bone and joint surgery American volume. Oct 16 2013;95(20):1869–76. doi:10.2106/jbjs.l.00679
Pivec R, Issa K, Kapadia BH, et al. Incidence and Future Projections of Periprosthetic Femoral Fracture Following Primary Total Hip Arthroplasty: An Analysis of International Registry Data. Journal of long-term effects of medical implants. 2015;25(4):269–75. doi:10.1615/jlongtermeffmedimplants.2015012625
Morrey BF. Difficult complications after hip joint replacement. Dislocation. Clin Orthop Relat Res. Nov 1997;(344):179–87.
Fujimaki H, Inaba Y, Kobayashi N, Tezuka T, Hirata Y, Saito T. Leg length discrepancy and lower limb alignment after total hip arthroplasty in unilateral hip osteoarthritis patients. Journal of orthopaedic science: official journal of the Japanese Orthopaedic Association. Nov 2013;18(6):969–76. doi:10.1007/s00776-013-0457-3

No competing interests reported.

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Primary Hip and Knee Arthroplasty at District Level Is Safe and May Reduce the Burden on Tertiary Care in a Low-income Setting

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