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Lancet 2018; 392: 1672–82 Knee replacement surgery is one of the most commonly done and cost-effective musculoskeletal surgical procedures. This is the second in a Series of The numbers of cases done continue to grow worldwide, with substantial variation in utilisation rates across regions two papers about hip and knee and countries. The main indication for surgery remains painful knee osteoarthritis with reduced function and quality replacement of life. The threshold for intervention is not well defined, and is influenced by many factors including patient and Nuffield Department of surgeon preference. Most patients have a very good clinical outcome after knee replacement, but multiple studies Orthopaedics, Rheumatology and Musculoskeletal Science, have reported that 20% or more of patients do not. So despite excellent long-term survivorship, more work is required Nuffield Orthopaedic Centre, to enhance this procedure and development is rightly focused on increasing the proportion of patients who have Oxford, UK (Prof A J Price FRCS, successful pain relief after surgery. Changing implant design has historically been a target for improving outcome, A Alvand FRCS, Prof A Carr FRCS, but there is greater recognition that improvements can be achieved by better implantation methods, avoidingProf D Beard DPhil); Department of Orthopaedic Surgery, complications, and improving perioperative care for patients, such as enhanced recovery programmes. New Copenhagen University technologies are likely to advance future knee replacement care further, but their introduction must be regulated and Hospital Hvidovre, monitored with greater rigour to ensure patient safety. Copenhagen, Denmark (Prof A Troelsen MD); Department of Orthopedic Introduction assessment of new devices and strategies to ensure Surgery and Division of Knee replacement surgery has been routinely done for patient safety in this process. Rheumatology, Brigham and more than 40 years and usage continues to grow Women's Hospital, Harvard Medical School, Boston, MA, worldwide. Its success is based on improving the quality Epidemiology of knee replacement USA (Prof J N Katz MD); of life for patients with knee arthritis by reducing pain The use of knee replacement as a treatment for arthritis Department of Orthopaedic and improving long-term function. However, 20% of continues to increase. In the UK, more than 100 000 knee Surgery and Musculoskeletal patients are dissatisfied with the outcome of surgery, and replacements are now done each year and a similar Medicine, University of Otago, research and development in the field focuses on this pattern of increased frequency is reported by many Christchurch, New Zealand (Prof G Hooper FRCS); and deficiency. This review concentrates on a number of worldwide joint registries.1–5 Total numbers of procedures Health Economics Research topical areas in knee replacement, starting with the in the USA have now reached 700 000 per year, and theCentre, Nuffield Department of epidemiology of knee replacement and the variability in number is increasing as predicted despite periods of Population Health, University of Oxford, Oxford, UK intervention rates alongside the indications for surgery. economic downturn (figure 1).6,7 Projected analyses from (Prof A Gray DPhil) The increasingly important role of patient-reported Correspondence to: outcomes and analysis of registry data is considered, Prof Andrew J Price, Nuffield together with an overview of the health–economic Key messages Department of Orthopaedics, evidence relating to knee replacement. Enhanced re • More than 95% of all knee replacements are done for Rheumatology and covery programmes are commonplace and have the osteoarthritisMusculoskeletal Science, Nuffield Orthopaedic Centre, potential to positively affect patient outcomes. De • Patients who undergo surgery usually have persistent Oxford OX3 7LD, UK velopment of new implants and supportive technologies symptoms of moderate or severe pain, and associated loss firstname.lastname@example.com. is continuously led by the industry, but more robust uk of function that has not responded to non-operative evidence to support their introduction is still required; measures we therefore review the regulatory requirements for • The average age of people undergoing knee replacement is about 65 years, but increasing numbers of knee replacement surgery are done in younger patients Search strategy and selection criteria • 80–85% of patients have successful treatment We searched MEDLINE and PubMed from Jan 1, 1970, to characterised by reduced pain, improved function, and April 30, 2018, using the search term "knee" in combination enhanced quality of life with "replacement", "joint", "total", "partial", "arthroplasty", • 15–20% of patients are dissatisfied with their outcome, "epidemiology", "mortality", "morbidity", "outcomes", usually characterised by ongoing pain and poor function "registry", "enhanced-recovery", "indications", "effectiveness", • Following implantation, a 65-year old patient has a "cost-effectiveness", "survivorship", "follow-up", "innovation", 7% lifetime risk of requiring revision surgery, but this risk "evaluation", and "regulation". We concentrated on results increases substantially with younger age groups from randomised trials, registries, and large population cohort • The most common reasons for revision surgery are studies. We mostly selected publications from 2010 to 2018, implant loosening, infection, pain, and instability but did not exclude commonly referenced and important older • 45-day mortality rates following knee replacement have publications. substantially decreased over time
A 10 2010 2000 250 Primary total hip arthroplasty
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30 operative therapy, to enable a decision that is consistent with their preferences and values. Knee replacement is 25 only one option for patients with advanced knee 20 osteoarthritis, and patients should be informed of 15 alternatives.29 For example, physical therapy programmes of strengthening and neuromuscular training can give 10 symptomatic improvement in two-thirds of patients with 5 advanced knee osteoarthritis.30 In this shared decision- making model, the patient and not the physician has the 0 50–54 55–59 60–64 65–69 70–74 75–79 80–84 ≥85 ultimate say over whether to proceed with surgery or not, Age at total knee replacement (years) based on their own individual assessment of the balanceFigure 3: Lifetime risk of revision after total knee replacement of risk versus capacity to benefit.21The plot shows the estimates of lifetime risk of total knee replacement revision against age at the time of primary This process is particularly important to both the oldertotal knee replacement surgery in 5-year age bands, and is stratified by sex. Shaded areas are 95% CIs. Results are and younger populations with osteoarthritis of the knee.adjusted for lost and censored population. Reproduced from Bayliss et al,16 by permission of Elsevier. For older individuals, a growing segment of this population are now living long enough to develop and severe end-stage osteoarthritis of the joint.21 functionally limiting knee osteoarthritis in the eighth or Historically, arthroplasty surgeons have been reluctant to ninth decade of their life. Despite their age and operate on patients with either morbid obesity (because comorbidities, this group is increasingly opting for total of the higher risk of perioperative complications), and on knee replacement to maintain their quality of life.2–4 patients younger than 55 years (because of the increased Likewise, younger patients are choosing to undergo knee likelihood of revision in their lifetime).15,22,23 Surgeons replacement for quality of life reasons, outweighing the have similarly been cautious about operating on patients increased risk of revision seen in this patient group. This with serious medical comorbidities, again for fear of move toward patient involvement in decision making complications but also on those with widespread pain and and research is further epitomised by a recent patient- or catastrophising behaviour, because these problems are focused James Lind Alliance Priority Setting Partnership, associated with higher risk of persistent pain.24,25 Finally, which was done in the UK, highlighting areas for future surgeons have historically set high levels of preoperative research in knee replacement (panel).31 pain and functional limitation to justify the risk of Indications for surgery can also be influenced by surgical intervention. health-care systems. Preoperative symptom thresholds Recent studies support expanding these traditional for knee replacement have recently been applied within indications. For example, although morbid obesity is the UK National Health System (NHS).32 So-called pay indeed associated with greater risk of perioperative for performance approaches, in which physicians are complications, such as postoperative infection, recent financially incentivised to restrict total knee replacement studies show that individuals with a body-mass index to those likely to have the best outcome (ie, individuals (BMI) of more than 35, and even more than 40, who are not obese or have fewer comorbidities), can experience similar pain relief as patients who are not potentially create conflict with patient preferences.33 obese.22,26 Similarly, studies have shown that patients with worse functional status preoperatively tend to have worse Patient-reported outcome after knee postoperative status, urging caution in permitting replacement surgery functional status to deteriorate while patients await total The evaluation of knee replacement has improved over knee replacement.27 Despite the higher risk of persistent time and the use of patient-reported outcome measures pain, patients with depression and catastrophising none have become more common and influential. A recent theless have, on average, marked improvements in pain systematic review showed 32 different measures that and function following surgery.24 have been used for this purpose, with the Western An important contributor to the contemporary Ontario and McMaster Universities Osteoarthritis broadening of indications of knee replacement is the (WOMAC), the Knee Injury and Osteoarthritis Outcome growing importance of the patient's voice in decisions Score, and the Oxford Knee Score (OKS) widely used.34 about whether to undertake surgery. Clinical guidance These instruments have shown that knee replacement from the UK National Institute for Health and Care improves quality of life for the majority of patients by Excellence and the American Academy of Orthopaedic substantially reducing pain and improving function.30,35–37 Surgeons, together with other authoritative bodies, em However, up to 15–20% of patients who have undergone phasise the importance of engaging patients in shared total knee replacement consider themselves to be
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assessment.44 Another approach is the personalisation of association between BMI and the cost-effectiveness of total outcome measurement, with some scores referencing knee replacement, and in general the single best predictor improvement from an individual's baseline.45 Such of postoperative costs, outcomes, and cost-effectiveness personalisation relies heavily on the complex inter- appears to be preoperative symptom severity.32,36 This effect relationship of patient expectation and satisfaction.46 might explain why one recent cost-effectiveness study by Exploring large datasets of patient-reported outcome Ferket and colleagues51 markedly differed from other measures has led to greater understanding of factors that analyses in concluding that total knee replacement in a affect functional outcome after knee replacement: recent US cohort of patients had very small effects on preoperative level of symptoms, expectation, comorbidity, quality of life and correspondingly poor levels of cost- age, and mental state.38,47 From interrogation of these effectiveness: their estimated preoperative quality-of-life large datasets, it is possible to calculate an individual's scores were very much less severe than those reported capacity to benefit from knee replacement.32 These tools in most other cohorts, trials, and registers, with a that estimate the range of outcome possible are likely to correspondingly much smaller postoperative improvement. be helpful in shared decision making. However predictive The only strictly randomised comparison of total knee models that attempt to determine final outcome for replacement with non-surgical treatment estimated the patients can only explain a modest proportion of the 1-year effect of surgery on quality of life to be about variability in outcome observed and as yet their three times that reported by Ferket and colleagues.30,51 An usefulness is unproven.38,47 economic evaluation based on the trial by Skou and colleagues30 has not yet been reported. Cost-effectiveness of knee replacement surgery In addition to the paucity of evidence from randomised As one of the most commonly done elective procedures studies, a major problem confronting cost-effectiveness in the world, total knee replacement has not surprisingly analyses of total knee replacement has been how to been the subject of a substantial number of cost- characterise the comparator—eg, is it usual care, intensified effectiveness analyses. Using the health economists' non-surgical care, or delayed surgery? Enhanced recovery favoured outcome measure—quality-adjusted life-years programmes for those undergoing total knee replacement (QALYs)—these studies have typically estimated the ratio are also attracting increasing interest and are being of incremental costs to health gain from total knee introduced in many NHS hospitals for patients undergoing replacement to be between approximately £1000 and hip and knee replacement.52 Robust cost-effectiveness on £12 000 for the average patient in different health-care such programmes is required and an ongoing systematic systems, which is well within the range that most review will be a useful first step.53 reimbursement and health technology assessment As the annual number of total knee replacements done bodies would consider representative of good value for continues to increase globally, it is reasonable to keep the money.35,36 cost-effectiveness of the procedure under review, These highly favourable results follow from the fact especially if it is being extended to patients who are much that total knee replacement in most countries is a younger or older, or have substantially more co relatively inexpensive procedure, and has been found by morbidities or less severe preoperative symptoms. How numerous studies to be associated with substantial and ever, it is also important to keep in mind that many sustained improvements from preoperative levels in patients who could benefit from total knee replacement, many domains of both disease-specific and generic and who would meet existing cost-effectiveness criteria, health-related quality-of-life measures, which is further are currently not getting access to this procedure because explored in a systematic review48 of 19 studies). In the of overall resource constraints, capacity shortages, or Knee Arthroplasty Trial, for example—one of the largest spending restrictions.32,36 and longest randomised trials of different types of total knee replacement—mean quality of life measured using Enhanced recovery after knee replacement surgery the EQ-5D (1=full health, 0=death) increased from Enhanced recovery programmes use a multimodal 0∙39 immediately before surgery to 0∙71 at 1 year and approach aimed at improving the care and subsequent declined only gradually thereafter.36 clinical outcome for patients undergoing knee arthroplasty. Although most studies have concluded that total knee First proposed in 1997,54 this approach aims to minimise replacement is in general a highly cost-effective procedure, the physiological and psychological stresses of surgery they have also reported substantial heterogeneity in costs through the use of specific interventions throughout the and benefits between patient subgroups. For example, total care pathway.55 The principal components of enhanced knee replacement appears to be more cost-effective in recovery programmes can be broadly thought of in terms younger patients, and in hospitals with higher volumes of of preoperative optimisation of patients' comorbidities, procedures.49 Interest has also focused on BMI, given patient education, perioperative anaesthetic techniques, increasing evidence that higher BMI values are associated perioperative surgical techniques, and postoperative with increased health-care costs for total knee replacement.50 rehabilitation. There is now growing evidence that such However, several analyses have not reported any clear programmes improve outcomes for knee arthroplasty
patients, with reduction in complications such as designs.1,4 The most common causes for revision reportedstroke, myocardial infarction, acute renal failure, and in national joint registries remains, in order of frequency:thromboembolic events potentially leading to reduced implant loosening, infection, pain, and instability, withmortality after surgery,56,57 as well as having profound the overall pattern of reported failure mechanism nothealth economic benefits.52 changing over the past 10 years.1–5 The leading cause of A major component of enhanced recovery programmes early revision following total knee arthroplasty continuesis the use of standardised anaesthetic protocols that to be periprosthetic joint infection.64 The effect of thisinclude spinal (ie, neuraxial) and regional anaesthesia. devastating complication on patients has been wellEvidence suggests that using these techniques in knee documented.65 Recent analysis of the first 15 years of thereplacement can reduce perioperative morbidity, reduce New Zealand Joint Registry has shown an increase inlength of hospital stay, and encourage faster functional early revision due to infection, and similar patterns arerecovery.58 The use of periarticular local infiltration of reported in Sweden and Australia.2–4 The increasinganaesthetic around the knee joint as part of a multimodal number of patients with knee periprosthetic jointanalgesic programme can also be as effective, if not infection has been partially ascribed to the increase insuperior, to regional blockade.59 The minimisation of the number of patients with diabetes or obesity, andblood loss is another important element of enhanced young patients undergoing knee arthroplasty.66,67 Recentrecovery programmes, and this element has resulted work has focused on improving the diagnosis ofin the adoption of tranexamic acid use, a practice that periprosthetic joint infection and more research iscan reduce transfusion requirement following total knee required to improve its treatment.68 Key to thisreplacement.60 Additionally, enhanced recovery pro improvement is the collection of more relevant outcomegrammes are adopting new evidence in prevention of data, including microbiological profile, antimicrobialvenous thromboembolism after knee replacement—for therapy, and the patient's general health status, withinstance, showing that aspirin is a reliable and cost- infection-specific outcomes linked to registry survivaleffective treatment option.61 results.69 Early mobilisation following surgery is favoured byknee arthroplasty enhanced recovery programmes and is New methodologies and roles for registriesassociated with reduced complications, reduced length of Joint replacement registries have been in use for manystay, and lower costs.62 The benefits of these programmes years to help monitor the outcome following kneeare now being applied to facilitate same-day or out- replacement surgery. The primary methodology has beenpatient knee arthroplasty in carefully selected patient identification of failing implants determined by agroups.63 calculation of device survival, using revision surgery as a hard endpoint. However, new methodologies and roles forJoint registries and knee replacement registries are being developed. Recently, the InternationalPatterns of implant use Society of Arthroplasty Registries, an organisation ofAnalysis of national registry data has become a national registries of 41 members, has included patient-cornerstone of assessment of knee replacement surgery, reported outcome measures to enable more patient-reinforced by improvements in data capture, as seen in specific data to help assess functional outcomes.70 Asthe UK National Joint Registry (UK NJR).1 Data from all stated before, it might be that a more sensitive measure ofpublished registries show expanding usage of knee the success on an implant is a combination of revisionreplacement over time, with women most likely to have and patient-reported outcome measures as endpoints. Insurgery, and increasing numbers of patients younger support of this concept is emerging evidence that scoresthan 60 years having surgery.1–5 Most implantations are of patient-reported outcome measures can predict earlycemented total knee replacements, with far fewer partial failure. The New Zealand Joint Registry, has shown that(unicompartmental) knee replacements being done. The an Oxford Knee Score less than 27 of 48 at 6 months wasmajority of prostheses implanted are established cruciate associated with a ten-times increased revision risk at 2 yearsretaining or posterior stabilised implants with long-track compared with a score of greater than 41.71 Such earlyrecords, but new implant modifications or new designs identification of patients at risk enables follow-up ofcontinue to be regularly introduced.1–5 The requirement vulnerable patients, providing better overall outcome andfor close scrutiny of any new implants is highlighted by reducing health expenditure.the introduction of the Beyond Compliance in the UK, Another substantial advance in the use of registries iswhich is working closely with the UK NJR and the ability to link them to other large national databases.the Orthopaedic Data Evaluation Panel, illustrating the For example in the UK NJR, data have been successfully For more on the Orthopaedicimportant role for registries to have in this process. linked to Hospital Episode Statistics and data of national Data Evaluation Panel see patient-reported outcome measures to identify a re- http://www.odep.org.ukPatterns of revision duction in mortality after knee replacement fromIn all registries, a revision rate of 3–5% at 10 years is 0∙37% in 2003 to 0∙20% in 2013, and reduced patientcommonly reported for many total knee replacement morbidity after partial when compared to total knee
arthroplasty.72,73 A further potential extension of knee (unicompartmental) knee replacement in the medial, replacement registry data is the development of registry- lateral, or patellofemoral compartment.1 The proposed based randomised controlled trials, increasing the power benefits of partial knee replacement over total knee of studies and decreasing cost.74 The evidence produced replacement include optimised functional outcome, from registries can also have a direct role in supporting lower postoperative length of stay, fewer medical the delivery of health services, as seen in the UK where complications, reduced re-admissions and mortality, the UK NJR reports are routinely used in individual and greater cost-effectiveness.82 Recent evidence from consultant appraisal and hospital level feedback, such as randomised con trolled trials has supported theseFor more on the Getting it Right the Getting it Right First Time process. findings, and results from other trials currently in First Time process see progress are awaited.44,83,84 The major argument against http://gettingitrightfirsttime. co.uk/ Development and new technology in knee wider adoption of partial knee replacement as an replacement surgery alternative to total knee replacement is the higher Design of total condylar knee replacement revision rate reported in nearly all national registry Posterior cruciate retaining or sacrificing total condylar reports.1,2,4 There is increasing evidence that the revision knee designs remain the two most widely used total knee rate for partial knee replacement is related to the number replacement options.1–3 Incremental design development performed or the proportion of partial knee replacement continues, such as gender-specific and high-flex com to total knee replacement undertaken by individual ponents, but evidence that these changes in component surgeons and units.85 In addition, recent registry shape produce any meaningful improvement in outcome evidence has suggested that with improved implantation is sparse.75 Most knee replacements still use a metal on methods, for instance the introduction of cementless polyethylene-bearing surface and polyethylene wear fixation, revision rates for partial knee replacement can remains a major cause of implant failure.1,2,4 Around be reduced.3 20 years ago, highly cross-linked polyethylene, so-called second-generation polyethylene, was introduced and Patient-specific instrumentation, computer navigation, has been successful in minimising polyethylene wear; and robotics thereby reducing aseptic loosening and revision.76 More Patient-specific instrumentation and computer recently, vitamin-E-infused, highly cross-linked poly- navigation have been introduced in knee arthroplasty ethylene, so-called third-generation or antioxidant poly surgery to help achieve more precise and accurate ethylene has been developed,77 but the efficacy of this alignment.86 The hope is that potential improvements polyethylene remains to be established. would lead to improved outcomes and, secondarily, to increased intraoperative and economic efficacy. Alignment in total knee replacement Literature reports are divergent, but overall there is little For more than 30 years, the standard approach to to suggest any clinically important difference in implant implanting total knee replacements has been to aim for component positioning, lower limb alignment, or mechanical alignment, where the hip, centre of the patient outcome is achieved compared with conventional reconstructed knee, and the ankle are in alignment.78 techniques.87–89 It could be speculated that the main More recently, kinematic alignment has been proposed as potential of patient-specific instrumentation or computer an alternative implantation strategy, aiming to mimic the navigation is to help less experienced, lower volume predisease joint surface orientation. This procedure is surgeons to achieve improved precision and accuracy, thought to optimise ligament balance and knee kine but this effect remains to be explored. There is some matics without the need for ligament releases.79 The evidence to suggest that computer navigation might global experience with kinematic alignment in total knee reduce revision rates in younger patients with total knee replacement is limited, but a recent literature review80 arthroplasty.90 Robotics in knee arthroplasty surgery has reported more favourable outcome after kinematically so far had a very limited introduction and high-quality aligned total knee replacement compared with mechanical comparative studies showing the potential efficacy over alignment; however, the improvement is not universal.81 conventional techniques are still required. In conclusion, The benefit from different alignment methods is possibly technology-based assistive techniques are still in the influenced by the pattern of osteoarthritis for each developmental phase and true benefits have yet to be individual patient. Mechanical alignment remains the identified.88 mostly widely used method of implantation and further investigation of the safety of kinematic alignment is The regulation and evaluation of innovation in needed before the technique can be considered for knee replacement surgery widespread use. The majority of medical devices and surgical implants, including knee replacements, are used without problem Partial knee replacement or concern, but in some situations problems have Most patients receive a total knee replacement implant, arisen. For example, in the use of metal-on-metal hip but currently approximately 8% of cases receive a partial replacements in which modifications to design resulted
in the production of excessive metal wear products, in stereophotogrammetric analysis can be effectively usedsome patients substantial local and sometimes systemic to identify implants with increased risk of late failure.99toxic effects were observed.91 As a result, the regulatory A systematic process that adopts multiple study designsauthorities throughout the world have begun to make for the safe introduction of implants is being developedchanges to their processes, and new frameworks for but as yet is not fully established.96evaluating medical devices have changed.92 In the past, Improvement of regulatory framework and the qualitymany surgical implants were introduced in the USA of evidence for introduction of surgical implants andwithout clinical evidence by the 510(k) route, based on a associated technology is essential.100 The process shouldcase of substantial equivalence rather than superiority support innovation in knee replacement surgery whileto a device already on the market.93 The recent changes protecting patients from the introduction of devices withto regulation have, in the USA, increased the use of insufficient evidence of safety or superiority (cost orpremarket approval, transparency, and justification efficacy) over existing treatments. In the context of anduring the submission process; and have allowed an already mature and generally successful technology, suchimprovement of the system of device recall, modified as knee replacement surgery, the process of improvedthe process of new applications to make them more regulation is key to identify technologies that offer truestringent, applied new processes to the review of benefit from those that offer no advantage, and at worstexisting devices, and fortified and reduced the use of the those that could cause harm.510(k) system.92 In Europe, the new rules established in2017 will continue to use notified bodies to grant CE Conclusionmarks, but with increased oversight by competent Knee replacement surgery is a highly successfulauthorities, and a new Medical Device Co-ordination established technology, with good evidence of successfulGroup will provide extra scrutiny for high-risk devices, treatment outcome and long-term implant survival. Asuch as knee replacement.94 The European Commission proportion of patients continue to have poor resultswill now be responsible for surveillance of implants and addressing this issue is the major challenge forthrough Eudamed, and high-risk implants will undergo improving care, particularly given the continuedassessment by the European Medicines Agency.92 increase in worldwide usage and the increasing numbers One specific problem associated with the innovation of younger patients undergoing surgery. Continued inand introduction of new knee implants into the market cremental changes in implant design do not appear tois demonstration of safety and benefit over existing have achieved any substantial improvement in outcometechnology.95 It is clear that new innovations need to be for patients, and focus could shift towards optimisingintroduced in a controlled step-wise manner using modifiable patient factors and the use of alternatives tomultiple study designs in a logical sequence that place total knee replacement, such as partial knee replacementthe minimum number of patients at risk.96 Benefit and perioperative management.beyond existing technology can only be tested effectively The field's understanding of patient-reportedthrough randomised trials, for which bias and con outcome of knee replacement has advanced, but it stillfounding are reduced and allows true determination of needs further refinement. National registries continueefficacy of one type of implant over another.97 Reliance to enable our understanding of knee replacement andon randomised trials is also far from ideal, as they are new analysis methodologies must be harnessed tovery costly, time consuming, and the validity of the maximise benefit. As with all medical areas, newresults might be limited to the study population only. technology is being developed at an increasing rate andThere are other barriers to surgical trials, in which the modernising regulatory change will help assessment ofclinical culture makes it difficult for surgeons to express implants and devices to maintain patient safety. Givenequipoise for different surgical techniques. Despite the existing success of established knee replacementthese issues, high-quality randomised controlled trials technology, more creative assessment methodologies,in knee replacement surgery are taking place.30,35,44,84 including more randomised controlled trials andRegistry data are less useful for comparative studies but adaptive designs, must be used when introducing neware capable of establishing temporal relationships of devices. Greater focus on patient involvement andoutcomes and adverse events with implantation of the maintaining patient safety in this process will help todevice, and evaluating rare exposures that might occur ensure knee replacement continues to be one of themany years after implantation.98 Registers are resource most successful surgical procedures in modernintensive, because large cohorts need to be followed up medicine.for many years to establish true assessment of risk, and Contributorsthere is the potential for non-representative study All authors participated in the literature review. AJP wrote thepopulations to arise from loss to follow-up. Ongoing introduction, conclusion, and the section on the epidemiology of knee replacement. AA wrote the section on enhanced recovery after kneework is required to determine the most cost-effective replacement surgery. AT wrote the section on development and newmanner to complete post-market surveillance of im technology in knee replacement surgery. JNK wrote the section onplanted devices. Other methodologies, such as roentgen indications for knee replacement surgery. GH wrote the section on joint
registries and knee replacement. AG wrote the section on the cost- 16 Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic effectiveness of knee replacement surgery. AC wrote the section on increase in total knee replacement utilization rates in the regulation and evaluation of innovation in knee replacement surgery. United States cannot be fully explained by growth in population DB wrote the section on patient-reported outcomes. size and the obesity epidemic. J Bone Joint Surg Am 2012; 94: 201–07. 17 Hanchate AD, Kapoor A, Katz JN, et al. Massachusetts health Declaration of interests reform and disparities in joint replacement use: difference in AJP has received funding from Zimmer Biomet and De Puy, and differences study. BMJ 2015; 350: h440. personal consultancy fees from Zimmer Biomet, during the conduct of 18 Falbrede I, Widmer M, Kurtz S, Schneidmüller D, Dudda M, the study. AT has received funding from Zimmer Biomet and De Puy, Röder C. Utilization rates of lower extremity prostheses in Germany and personal consultancy fees from Zimmer Biomet, during the conduct and Switzerland: a comparison of the years 2005–08. of the study. All other authors declare no competing interests. Orthopade 2011; 40: 793–801. 19 NiemeläInen MJ, MäKelä KT, Robertsson O, et al. Acknowledgments Different incidences of knee arthroplasty in the Nordic countries: Support was received from the UK National Institute for Health a population-based study from the Nordic Arthroplasty Register Research Oxford Musculoskeletal Biomedical Research Centre. Association. Acta Orthop 2017; 88: 173–78. References 20 McCulloch P, Nagendran M, Campbell WB, et al. Strategies to 1 National Joint Registry. 14th annual report 2017. National Joint reduce variation in the use of surgery. Lancet 2013; 382: 1130–39. Registry for England, Wales, Northern Ireland and the Isle of Man: 21 Dieppe P, Lim K, Lohmander S. Who should have knee joint surgical data to 31 December 2016. 2017. http://www.njrreports.org. replacement surgery for osteoarthritis? Int J Rheum Dis 2011; uk/Portals/0/PDFdownloads/NJR%2014th%20Annual%20 14: 175–80. Report%202017.pdf (accessed March 31, 2018). 22 Kerkhoffs GMMJ, Servien E, Dunn W, Dahm D, Bramer JAM, 2 Australian Orthopaedic Association National Joint Replacement Haverkamp D. The influence of obesity on the complication rate Registry. Hip, knee & shoulder arthroplasty: annual report 2017. and outcome of total knee arthroplasty: a meta-analysis and https://aoanjrr.sahmri.com/annual-reports-2017 systematic literature review. J Bone Joint Surg Am 2012; 94: 1839–44. (accessed March 1, 2018). 23 Alvi HM, Mednick RE, Krishnan V, Kwansny MJ, Beal MD, 3 New Zealand Joint Registry. The New Zealand Joint Registry: Manning DW. The effect of BMI on 30 day outcomes following total eighteen year report January 1999 to December 2016. 2017. joint arthroplasty. 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American Joint Registry 2017 pain and functional recovery following total knee arthroplasty. annual report. 2017. http://connect.ajrr.net/2017-annual-report- J Bone Joint Surg Am 2017; 99: 1812–18. download?hsCtaTracking=211910d3-f75a-440c-8bff- 27 Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint 9d3da22c75ad%7C2cb33f5d-6e5a-405d-b3c6-dc5e1914c660 replacement affects clinical outcomes among patients with (accessed April 30, 2018). osteoarthritis of the hip or knee. Arthritis Rheum 2002; 46: 3327–30. 6 Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic 28 Manner PA, Tubb CC, Levine BR. AAOS appropriate use criteria: downturn on total joint replacement demand in the United States: surgical management of osteoarthritis of the knee. updated projections to 2021. J Bone Joint Surg Am 2014; J Am Acad Orthop Surg 2018; 26: e194–97. 96: 624–30. 29 NICE. Osteoarthritis: care and management. Clinical guideline 7 Weinstein AM, Rome BN, Reichmann WM, et al. Estimating the [CG177]. 2014. https://www.nice.org.uk/guidance/cg177 burden of total knee replacement in the United States. (accessed April 30, 2018). J Bone Joint Surg Am 2013; 95: 385–92. 30 Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled 8 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. trial of total knee replacement. N Engl J Med 2015; 373: 1597–606. Projected increase in total knee arthroplasty in the United States— an alternative projection model. Osteoarthritis Cartilage 2017; 31 James Lind Alliance Priority Setting Partnership. Hip & knee 25: 1797–803. replacement for osteoarthritis top 10. 2014. http://www.jla.nihr. ac.uk/priority-setting-partnerships/hip-and-knee-replacement-for- 9 Culliford D, Maskell J, Judge A, et al. Future projections of total hip osteoarthritis/top-10-priorities/ (accessed March 1, 2018). and knee arthroplasty in the UK: results from the UK Clinical Practice Research Datalink. Osteoarthritis Cartilage 2015; 32 Price AJ, Smith J, Dakin HA, et al. Introducing standardized and 23: 594–600. evidence based thresholds for hip and knee replacement surgery— the arthroplasty candidacy help engine (the ACHE tool): 10 Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of a systematic review, clinical and economics analysis. total hip and knee replacement in the United States. Health Technol Assess (in press). J Bone Joint Surg Am 2015; 97: 1386–97. 33 Giori NJ, Amanatullah DF, Gupta S, Bowe T, Harris AHS. 11 Culliford DJ, Maskell J, Kiran A, et al. The lifetime risk of total hip Risk reduction compared with access to care: quantifying the and knee arthroplasty: results from the UK general practice trade-off of enforcing a body mass index eligibility criterion for joint research database. Osteoarthritis Cartilage 2012; 20: 519–24. replacement. J Bone Joint Surg Am 2018; 100: 539–45. 12 Turkiewicz A, Petersson IF, Björk J, et al. Current and future 34 Harris K, Dawson J, Gibbons E, et al. Systematic review of impact of osteoarthritis on health care: a population-based study measurement properties of patient-reported outcome measures with projections to year 2032. Osteoarthritis Cartilage 2014; used in patients undergoing hip and knee arthroplasty. 22: 1826–32. Patient Relat Outcome Meas 2016; 7: 101–08. 13 Young BL, Watson SL, Perez JL, McGwin G, Singh JA, Ponce BA. 35 Murray DW, MacLennan GS, Breeman S, et al. A randomised Trends in joint replacement surgery in patients with rheumatoid controlled trial of the clinical effectiveness and cost-effectiveness of arthritis. J Rheumatol 2017; 45: 158–64. different knee prostheses: the Knee Arthroplasty Trial (KAT). 14 Pabinger C, Lothaller H, Geissler A. Utilization rates of Health Technol Assess 2014; 18: 1–235. knee-arthroplasty in OECD countries. Osteoarthritis Cartilage 2015; 36 Dakin H, Gray A, Fitzpatrick R, MacLennan G, Murray D. 23: 1664–73. Rationing of total knee replacement: a cost-effectiveness analysis on 15 Bayliss LE, Culliford D, Monk AP, et al. The effect of patient age at a large trial data set. BMJ Open 2012; 2: e000332. intervention on risk of implant revision after total replacement of 37 Williams DP, Blakey CM, Hadfield SG, Murray DW, Price AJ, the hip or knee: a population-based cohort study. Lancet 2017; Field RE. Long-term trends in the Oxford knee score following total 389: 1424–30. knee replacement. Bone Joint J 2013; 95–B: 45–51.
38 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. 60 Chen T, Chen Y, Jiao J, et al. Comparison of the effectiveness and What proportion of patients report long-term pain after total safety of topical versus intravenous tranexamic acid in primary total hip or knee replacement for osteoarthritis? A systematic review of knee arthroplasty: a meta-analysis of randomized controlled trials. prospective studies in unselected patients. BMJ Open 2012; J Orthop Surg Res 2017; 12: 11. 2: e000435. 61 NICE. Venous thromboembolism in over 16s: reducing the risk of39 Beard DJ, Harris K, Dawson J, et al. Meaningful changes for the hospital-acquired deep vein thrombosis or pulmonary embolism. Oxford hip and knee scores after joint replacement surgery. 2018. https://www.nice.org.uk/guidance/ng89 J Clin Epidemiol 2015; 68: 73–79. (accessed Aug 8, 2018).40 Lange T, Rataj E, Kopkow C, Lützner J, Günther K-P, Schmitt J. 62 Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who Outcome assessment in total knee arthroplasty: a systematic review have had a hip or knee joint replacement reduces length of stay in and critical appraisal. J Arthroplasty 2017; 32: 653–65. hospital: a systematic review. Clin Rehabil 2015; 29: 844–54.41 Hawker GA, Badley EM, Borkhoff CM, et al. Which patients are most 63 Kort NP, Bemelmans YFL, van der Kuy PHM, Jansen J, likely to benefit from total joint arthroplasty? Arthritis Rheum 2013; Schotanus MGM. Patient selection criteria for outpatient joint 650: 1243–52. arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25: 2668–75.42 NHS Digital. Provisional quarterly patient reported outcome measures 64 Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW. Periprosthetic (PROMs) in England, April 2016 to March 2017. 2018. http://digital. joint infection is the main cause of failure for modern knee nhs.uk/catalogue/PUB30192 (accessed March 31, 2018). arthroplasty: an analysis of 11 134 knees. Clin Orthop Relat Res 2017;43 Escobar A, Gonzalez M, Quintana JM, et al. Patient acceptable 475: 2194–201. symptom state and OMERACT-OARSI set of responder criteria in 65 Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. joint replacement. Identification of cut-off values. Periprosthetic joint infection increases the risk of one-year Osteoarthritis Cartilage 2012; 20: 87–92. mortality. J Bone Joint Surg Am 2013; 95: 2177–84.44 Beard D, Price A, Cook J, et al. Total or Partial Knee Arthroplasty 66 O'Toole P, Maltenfort MG, Chen AF, Parvizi J. Projected Increase Trial—TOPKAT: study protocol for a randomised controlled trial. in periprosthetic joint infections secondary to rise in diabetes and Trials 2013; 14: 292. obesity. J Arthroplasty 2016; 31: 7–10.45 Noble PC, Scuderi GR, Brekke AC, et al. Development of a new knee 67 Meehan JP, Danielsen B, Kim SH, Jamali AA, White RH. society scoring system. Clin Orthop Relat Res 2012; 470: 20–32. Younger age is associated with a higher risk of early periprosthetic46 Dunbar MJ, Richardson G, Robertsson O. I can't get no satisfaction joint infection and aseptic mechanical failure after total knee after my total knee replacement: rhymes and reasons. arthroplasty. J Bone Joint Surg Am 2014; 96: 529–35. Bone Joint J 2013; 95-B (suppl 11A): 148–52. 68 Zmistowski B, Della Valle C, Bauer TW, et al. Diagnosis of47 Arden N, Altman D, Beard D, et al. Lower limb arthroplasty: periprosthetic joint infection. J Arthroplasty 2014; 29 (suppl 2): 77–83. can we produce a tool to predict outcome and failure, and is it 69 Haddad FS, George DA. Can national joint registries play a role in cost-effective? An epidemiological study. improving our understanding of periprosthetic infections? Program Grants Appl Res 2017; 50: 1–246. Bone Joint J 2016; 98-B: 289–90.48 Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and 70 Rolfson O, Bohm E, Franklin P, et al. Patient-reported outcome long-term quality of life after total knee replacement: a systematic measures in arthroplasty registries: report of the Patient-Reported review and meta-analysis. J Bone Joint Surg Am 2015; 97: 156–68. Outcome Measures Working Group of the International Society of49 Losina E, Walensky RP, Kessler CL, et al. Cost-effectiveness of total Arthroplasty Registries. Part II. Recommendations for selection, knee arthroplasty in the United States: patient risk and hospital administration, and analysis. Acta Orthop 2016; 87: 9–23. volume. Arch Intern Med 2009; 169: 1113–21. 71 Rothwell AG, Hooper GJ, Hobbs A, Frampton CM. An analysis of50 Kent S, Green J, Reeves G, et al. Hospital costs in relation to the Oxford hip and knee scores and their relationship to early joint body-mass index in 1·1 million women in England: a prospective revision in the New Zealand Joint Registry. J Bone Joint Surg Am cohort study. Lancet Public Health 2017; 2: e214–22. 2010; 92-B: 413–18.51 Ferket BS, Feldman Z, Zhou J, Oei EH, Bierma-Zeinstra SMA, 72 Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes Mazumdar M. Impact of total knee replacement practice: cost after total and unicompartmental knee replacement in effectiveness analysis of data from the Osteoarthritis Initiative. 101 330 matched patients: a study of data from the National Joint BMJ 2017; 356: j1131. Registry for England and Wales. Lancet 2014; 384: 1437–45.52 Duncan CM, Long KH, Warner DO, Pagnano MW, Hebl JR. 73 Hunt LP, Ben-Shlomo Y, Clark EM, et al. 45-day mortality after The economic implications of a multimodal analgesic regimen 467 779 knee replacements for osteoarthritis from the National combined with minimally invasive orthopedic surgery: a comparative Joint Registry for England and Wales: an observational study. cost study. J Anesth Clin Res 2010; 1: 1–6. Lancet 2014; 384: 1429–36.53 Murphy J, Pritchard MG, Cheng LY, Janarthanan R, Leal J. 74 Lauer MS, D'Agostino RB. The Randomized Registry Trial—the Cost-effectiveness of enhanced recovery in hip and knee replacement: next disruptive technology in clinical research? N Engl J Med 2013; a systematic review protocol. BMJ Open 2018; 8: e019740. 369: 1579–81.54 Kehlet H. Multimodal approach to control postoperative 75 Nieuwenhuijse MJ, Nelissen RGHH, Schoones JW, Sedrakyan A. pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606–17. Appraisal of evidence base for introduction of new implants in hip55 Soffin EM, Yadeau JT. Enhanced recovery after surgery for primary and knee replacement: a systematic review of five widely used hip and knee arthroplasty: a review of the evidence. device technologies. BMJ 2014; 349: g5133. Br J Anaesth 2016; 117: 62–72. 76 De Steiger RN, Muratoglu O, Lorimer M, Cuthbert AR, Graves SE.56 Savaridas T, Serrano-Pedraza I, Khan SK, Martin K, Malviya A, Lower prosthesis-specific 10-year revision rate with crosslinked Reed MR. Reduced medium-term mortality following primary total than with non-crosslinked polyethylene in primary total knee hip and knee arthroplasty with an enhanced recovery program. arthroplasty. Acta Orthop 2015; 86: 721–27. Acta Orthop 2013; 84: 40–43. 77 Nebergall AK, Troelsen A, Rubash HE, Malchau H, Rolfson O,57 Malviya A, Martin K, Harper I, et al. Enhanced recovery program for Greene ME. Five-year experience of vitamin E-diffused hip and knee replacement reduces death rate: a study of highly cross-linked polyethylene wear in total hip arthroplasty 4500 consecutive primary hip and knee replacements. assessed by radiostereometric analysis. J Arthroplasty 2016; Acta Orthop 2011; 82: 577–81. 31: 1251–55.58 Johnson RL, Kopp SL, Burkle CM, et al. Neuraxial vs general 78 Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee anaesthesia for total hip and total knee arthroplasty: a systematic arthroplasty. Clin Orthop Relat Res 1985; 192: 13–22. review of comparative-effectiveness research. Br J Anaesth 2016; 79 Rivière C, Iranpour F, Auvinet E, et al. Alignment options for total 116: 163–76. knee arthroplasty: a systematic review.59 Hu B, Lin T, Yan S, et al. Local infiltration analgesia versus regional Orthop Traumatol Surg Res 2017; 103: 1047–56. blockade for postoperative analgesia in total knee arthroplasty: 80 Courtney PM, Lee G-C. Early outcomes of kinematic alignment in a meta-analysis of randomized controlled trials. Pain Physician 2016; primary total knee arthroplasty: a meta-analysis of the literature. 19: 205. J Arthroplasty 2017; 32: 2028–32.
81 Young SW, Walker ML, Bayan A, Briant-Evans T, Pavlou P, 90 De Steiger RN, Liu YL, Graves SE. Computer navigation for total Farrington B. The Chitranjan S. Ranawat Award: no difference in knee arthroplasty reduces revision rate for patients less than 2-year functional outcomes using kinematic versus mechanical sixty-five years of age. J Bone Joint Surg Am 2015; 97: 635–42. alignment in TKA: a randomized controlled clinical trial. 91 Smith AJ, Dieppe P, Howard PW, Blom AW. Failure rates of Clin Orthop Relat Res 2017; 475: 9–20. metal-on-metal hip resurfacings: analysis of data from the National 82 Burn E, Liddle AD, Hamilton TW, et al. Cost-effectiveness of Joint Registry for England and Wales. Lancet 2012; 380: 1759–66. unicompartmental compared with total knee replacement: 92 Sorenson C, Drummond M. Improving medical device regulation: a population-based study using data from the National Joint the United States and Europe in perspective. Milbank Q 2014; Registry for England and Wales. BMJ Open 2018; 8: e020977. 92: 114–50. 83 Kulshrestha V, Datta B, Kumar S, Mittal G. Outcome of 93 Sheth U, Nguyen N, Gaines S, Bhandari M, Mehlman C, Klein G. unicondylar knee arthroplasty vs total knee arthroplasty for early New orthopedic devices and the FDA. medial compartment arthritis: a randomized study. J Long Term Eff Med Implant 2009; 19: 173–84. J Arthroplasty 2017; 32: 1460–69. 94 UK Medicines and Healthcare products Regulatory Agency. 84 Odgaard A, Madsen F, Wagner Kristensen P, Kappel A, Fabrin J. Guidance: notified bodies for medical devices. 2017. https://www. The Mark Coventry Award: patellofemoral arthroplasty results in gov.uk/government/publications/notified-bodies-for-medical- better range of movement and early patient-reported outcomes devices/notified-bodies-for-medical-devices than TKA. Clin Orthop Relat Res 2018; 476: 87–100. (accessed March 28, 2018). 85 Liddle AD, Pandit H, Judge A, Murray DW. Optimal usage of 95 Anand R, Graves SE, de Steiger RN, et al. What Is the benefit of unicompartmental knee arthroplasty: a study of 41 986 cases from introducing new hip and knee prostheses? the national joint registry for England and Wales. Bone Joint J 2015; J Bone Joint Surg Am 2011; 93 (suppl 3): 51–54. 97-B: 1506–11. 96 Pijls BG, Nelissen RGHH. The era of phased introduction of new 86 Gromov K, Korchi M, Thomsen MG, Husted H, Troelsen A. What is implants. Bone Joint Res 2016; 5: 215–17. the optimal alignment of the tibial and femoral components in knee 97 Faris O, Shuren J. An FDA viewpoint on unique considerations for arthroplasty? An overview of the literature. Acta Orthop 2014; medical-device clinical trials. N Engl J Med 2017; 376: 1350–57. 85: 480–87. 98 Malchau H, Graves SE, Porter M, Harris WH, Troelsen A. The next 87 Huijbregts HJ, Khan RJ, Sorensen E, Fick DP, Haebich S. critical role of orthopedic registries. Acta Orthop 2015; 86: 3–4. Patient-specific instrumentation does not improve radiographic 99 Nelissen RGHH, Pijls BG, Kärrholm J, Malchau H, alignment or clinical outcomes after total knee arthroplasty. Nieuwenhuijse MJ, Valstar ER. RSA and registries: the quest for Acta Orthop 2016; 87: 386–94. phased introduction of new implants. J Bone Joint Surg Am 2011; 88 van der List JP, Chawla H, Joskowicz L, Pearle AD. Current state of 93 (suppl 3): 62–65. computer navigation and robotics in unicompartmental and total 100 Sedrakyan A, Campbell B, Merino JG, Kuntz R, Hirst A, knee arthroplasty: a systematic review with meta-analysis. McCulloch P. IDEAL-D: a rational framework for evaluating and Knee Surg Sports Traumatol Arthrosc 2016; 24: 3482–95. regulating the use of medical devices. BMJ 2016; 353: 1–7. 89 Sassoon A, Nam D, Nunley R, Barrack R. Systematic review of patient-specific instrumentation in total knee arthroplasty: new but not improved. Clin Orthop Relat Res 2015; 473: 151–58. © 2018 Elsevier Ltd. All rights reserved.


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Econo Lodge International Drive
- Free continental breakfast, free WiFi, and free parking
- Collect nights
Econo Lodge International Drivefrom A$72
- Standard Double Room, 2 Double Beds, Non Smoking
- Room, 1 King Bed
More great choices
What's around Econo Lodge International Drive
- In Southwest Orlando
- The Wheel at ICON Park™ - 21 min walk
- Universal Orlando Resort™ - 31 min walk
- Universal Studios Florida™ - 32 min walk
- Pointe Orlando - 35 min walk
- Universal CityWalk™ - 36 min walk
- Orlando International Premium Outlets - 42 min walk
- Universal's Islands of Adventure™ - 43 min walk
Getting around
- Orlando, FL (MCO-Orlando Intl.) - 22 min drive
- Kissimmee, FL (ISM-Kissimmee Gateway) - 32 min drive
- Orlando, FL (SFB-Orlando Sanford Intl.) - 44 min drive
- Orlando Station - 16 min drive
- Winter Park Station - 26 min drive
- Kissimmee Station - 31 min drive
- Free theme park shuttle
At a glance
Key facts
Hotel size
- This hotel has 118 rooms
- This hotel is arranged over 3 floors
- Check-in time 3 PM-midnight
- Check-out time is 11 AM
- Express check-in/out
Required at check-in
- Credit card or cash deposit required
- Government-issued photo ID required
- Minimum check-in age is 18
- Minimum Spring Break check-in age is 21
Travelling with others
- Children stay free when occupying the parent or guardian's room, using existing bedding
- Pets not allowed (service animals welcome)
- Free WiFi in public areas
- Free WiFi in rooms
- Free self parking
- Free RV/bus/truck parking
- Free theme park shuttle
Payment types at the property
Other information
- Smoke-free property
In the hotel
- Free continental breakfast daily
- Outdoor pool
- Pool umbrellas
- Business centre
- Conference centre
- 24-hour front desk
- Tours/ticket assistance
- Limo or Town Car service available
- Laundry facilities
- Luggage storage
- Multilingual staff
- Number of buildings/towers - 2
- Lift
- ATM/banking
- Picnic area
- Television in common areas
- Braille or raised signage
- Accessible bathroom
- Wheelchair accessible
- Wheelchair-accessible parking
- Assistive listening devices available
- Arabic
- English
- French
- Spanish
In the room
- In-room climate control (air conditioning)
- Air conditioning
- Coffee/tea maker
- Iron/ironing board
- Blackout drapes/curtains
- Private bathroom
- Bathtub or shower
- Hair dryer
- 32-inch flat-screen TV
- Cable TV channels
- Desk
- Free weekday newspaper
- Free WiFi
- Free local calls
- Fridge
- Daily housekeeping
- In-room safe
- Connecting/adjoining rooms available
- Access via exterior corridors
Recommended hotels
Econo Lodge International Drive's small print
Also known as
- Econo Lodge International Drive Hotel Orlando
- Orlando Econo Lodge
- Econo Lodge International Drive Orlando
- Econo Drive Orlando
- Econo Lodge International Drive Hotel
- Econo Lodge International Drive Orlando
- Econo Lodge International Drive Hotel Orlando
- Econo Lodge International Drive Hotel
- Econo Lodge International Drive Orlando
- Econo Lodge International Drive
- Econo Lodge Inn And Suites International Drive
- Orlando Econo Lodge
- Econo Lodge Orlando
- Econo Lodge Inn & Suites International Drive Hotel Orlando
- Econolodge Hotel Orlando
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
Noise-free guestrooms cannot be guaranteed.
Only registered guests are allowed in the guestrooms.
Parking height restrictions apply.
Mandatory fees
You'll be asked to pay the following charges at check-in or check-out:
Deposit: USD 50.00 per stay
- Resort fee: USD 4.95 per accommodation, per night
Resort fee inclusions:
- Shuttle service
- In-room safe
- Parking
Inclusions may be listed elsewhere on the page as free or for a surcharge.
Optional extras
Early check-in can be arranged for an extra charge of USD 25.00 (subject to availability)
Late check-out can be arranged for an extra charge of USD 25.00 (subject to availability)
Rollaway beds are available for USD 10.00 per night
We have included all charges provided to us by this property. However, charges can vary, for example, based on length of stay or the unit you book.
Most helpful reviews
Good 6.8 From 229 reviews
Worked fine as a place to sleep and shower. Towels had to be checked before using as they had long black hairs ingrained into the fibers and sometimes had stains and footprints on them. On the third day of our week long stay, the housekeeping staff removed the bedding from our rooms and did not replace the blankets. We came back to the room late at night and only had sheets on the bed. We had to go down to the main office to request blankets. They were provided, but had stains on them. The blankets provided were never removed from the room after that point or washed. It was very obvious that the housekeeping staff chose to make the beds, rather than replace the bedding as there were still pillows on the floor in the corner of the room and the blankets remaining were the ones given to us after ours had been removed. Was relatively clean and updated, except for the bathroom. Bathroom tiles had significant staining. Fan in bathroom only worked occasionally, requiring us to keep the bathroom door open when showering. Laundry is provided, but it is located outside in the breezeway, which happened to be next to our room. We could hear it running at night and in the early morning, which was disruptive. Elevators were helpful in getting our bags to the third floor, although they took a long time. Vending machines in the exterior of the building had snack options, but most were melted chocolate bars. Continental breakfast was supposedly provided, but we did not see any.
As a solo female traveller, I was initially pleased to find what seemed to be a conveniently located and affordable room at Econo Lodge while I explored the theme parks of Orlando. Unfortunately, my planned week long stay was cut short to only 2 nights due to the theft of my laptop along with a bag of toiletries from my room while I went to shop for a few hours in mid January 2018 (my in-room safe was not working). The police involved in this incident strongly suspect one of the staff members. Reception was helpful in calling police and refunding the remaining nights, however the manager who took down my details has never contacted me with any update or findings from their CCTV footage of who entered my room during a period of only 3 hours that I was out, and of course I have not seen my belongings since. Apparently, there was also theft from another room on the same night. Econo Lodge falsely advertised that each room has coffee makers. In fact, the only way to obtain hot water is to access the coffee machine in the lobby during strict breakfast hours, or use the 1 microwave in the lobby. For the theme park shuttles, there is only 1 pick up time per day and no system to ensure you get a seat if it's very busy. "Breakfast" is pre-packaged icing-laden pastries and mouldy oranges. They have a basic coffee machine and juice dispenser which operates only during breakfast hours, when the tiny lobby overflows with people and there are not enough seats/tables for everyone.
The hotel was decently okay for the night I spent. The room was clean, and the beds were clean and comfortable. I liked the mini-fridge and the Wi-Fi was satisfactory. As for the amenities and lavishness of the room...quite frankly, you get what you pay for. This is a no-frills hotel. But it's good if you're just staying at night and going out in the morning. I had a good stay overall with two exceptions. First, the check-in process, while okay, charged a $4.95 additional resort fee not included on my reservation. While it's understandable, I was told that if I was going to pay in cash, I would have to give a $50 deposit to the hotel. Really? That makes complete sense. Pay $5 and then give $50. This makes no sense for such a small amount and I am very dis-satisfied at the lack of consideration this hotel has and naïveté of its management. Additionally, the hotel has all my credit card credentials from the booking so there should be no need to collect any moneys with regard to "accidental" or "deposit" fees. I was forced to use my credit card for this, which made me deeply unsatisfied that a hotel would collect $50 on a payment of a simple $4.95 fee. Next, the room, while pretty good, did feel a musty and damp feeling at first - like a lack of air circulation. It eventually dissipated with the A/C but nevertheless, it was a nuisance, I am not certain as to other rooms. While I would recommend, this hotel needs to modify it's cash policy and use A/C more!
We booked this hotel for a last minute trip to Universal Studios. We were looking for a hotel close by, safe, and budget friendly and we got what we asked for. Check in was uneventful. Room was clean though some minor maintenance could be done. Beds were normal hotel grade, pillows were the cheap ones that flatten out after a few minutes but we always bring our own. Hardwood floors, no carpet. Refrigerator but no microwave or coffee maker which I thought was advertised. We were on the first floor and able to park right outside the door which made packing and unpacking easy. Location was less than a 10 minute drive to Universal and within walking distance of many touristy areas and restaurants. Getting in and out during prime nighttime activities can be challenging but we didn't really have any problems. My only complaints are 1. We were not stocked with enough towels and wash cloths for us all to shower daily. And when we asked for more, they never showed. I had to share my sons! 2. On the second night after returning from the theme park neither of our keys would work and I had to go to the desk and wait in line to have them fixed. This must be a common problem because when I was checking in two other customers came in for the same reason. Overall, I was happy with our stay. It was the cheapest in the area I could find and allowed us to shower and sleep peacefully for our 2 night stay.
A recent reservation was made at this hotel for crew members who work overnight on a job site. The reservation was for 5 nights, on the 4th day our lead crew member was treated very disrespectfully and rudely by not one but several employees - including the Manager/Owner of this location. After receiving an upsetting call from the crew, I placed a call to this location in hopes to remedy the confusion, I was then treated with a disrespectful and rude attitude over the phone and told I was wasting the Manager/Owner's time on the phone and then was hung up on. If you are looking for lodging near the Universal/Orlando area DO NOT stay here. There are plenty of other reasonable priced accommodations who don't treat their guests as poorly as our crew members were nor do they kick them out of their room for a non-sense policy about cleaning a room - even when the guest has DO NOT DISTURB sign, which is a violation of privacy when ignored and taken out of the key card slot to open the door. Econo Lodge corporate office will be getting an email and phone call in regard to this situation, and our company WILL NOT be staying at this location again. DO NOT STAY HERE!
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Back to all reports
Appears abandoned
Reported via iOS in the Abandoned vehicles category by Mr Ian R White at 11:53, Saturday 16 November 2019
Sent to South Oxfordshire District Council 2 minutes later
This car has been parked here for at least a week, hasn't moved and appears to have been abandoned. The tires more look to be under inflated albeit that they are low profile.
Might have been stolen and dumped
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so I saw a story that was really fascinating who's like 800 or a thousand words in The Washington Post today about Camilla parker-bowles you know the hmm the woman that Prince Charles was I'm trying to be really good here and be nice the woman that Prince Charles was seeing behind Princess Diana's back you know cuz she was such a skank anyway Camilla she sent the press a message yesterday she was standing there in their living room or the drawing room or the calling room or whatever the room that was with the fireplace and the couches and things and they took some pictures in front of the president she has Trump turned back she turned to the press and winked and she was like hmm I'm so naughty and the Washington Post said what did Camila's wink mean what was she telling us with that wink as though something is going down oh they were so Randi yesterday in England it was crazy so I will all I thought I would do today is just speak to the Washington Post directly and and tell them here's
How do I fill out the Rai Publication Scholarship Form 2019?
Rai Publication Scholarship Exam 2019- Rai Publication Scholarship Form 5th, 8th, 10th & 12th.Rai Publication Scholarship Examination 2019 is going to held in 2019 for various standards 5th, 8th, 10th & 12th in which interested candidates can apply for the following scholarship examination going to held in 2019. This scholarship exam is organized by the Rai Publication which will held only in Rajasthan in the year 2019. Students can apply for the following scholarship examination 2019 before the last date of application that is 15 January 2019. The exam will be conducted district wise in Rajasthan State by the Rai Publication before June 2019.Students of class 5th, 8th, 10th and 12th can fill online registration for Rai Publication scholarship exam 2019. Exam is held in February in all districts of Rajasthan. Open registration form using link given below.In the scholarship examination, the scholarship will be given to the 20 topper students from each standard of 5th, 8th, 10th & 12th on the basis of lottery which will be equally distributed among all 20 students. The declaration of the prize will be announced by July 2019.राय पब्लिकेशन छात्रव्रत्ति परीक्षा का आयोजन सत्र 2019 में किया जाएगा कक्षा 5वी , 8वी , 10वी एवं 12वी के लिए, इच्छुक अभ्यार्थी आवेदन कर सकते है इस छात्रव्रत्ति परीक्षा 2019 के लिए | यह छात्रव्रत्ति परीक्षा राजस्थान में राइ पब्लिकेशन के दवारा की जयगी सत्र 2019 में | इच्छुक अभ्यार्थी एक परीक्षा कर सकते है आखरी तारीख 15 जनवरी 2019 से पहले | यह परिखा राजस्थान छेत्र में जिला स्तर पर कराई जाएगी राइ पब्लिकेशन के दवारा जून 2019 से पहले |इस छात्रव्रत्ति परीक्षा में, छात्रव्रत्ति 20 विजेता छात्र छात्राओं दो दी जयेगी जिसमे हर कक्षा के 20 छात्र होंगे जिन्हे बराबरी में बाटा जयेगा। पुरस्कार की घोसणा जुलाई 2019 में की जयेगी |Rai Publication Scholarship Exam 2019 information :This scholarship examination is conducted for 5th, 8th, 10th & 12th standard for which interested candidates can apply which a great opportunity for the students. The exam syllabus will be based according to the standards of their exam which might help them in scoring in the Rai Publication Scholarship Examination 2019. The question in the exam will be multiple choice questions (MCQ's) and there will be 100 multiple choice questions. To apply for the above scholarship students must have to fill the application form but the 15 January 2019.यह छात्रव्रत्ति परीक्षा कक्षा कक्षा 5वी , 8वी , 10वी एवं 12वी के लिए आयोजित है जिसमे इच्छुक अभ्यार्थी पंजीकरण करा सकते है जोकि छात्र छात्राओं के लिए एक बड़ा अवसर होगा | राय पब्लिकेशन छात्रव्रत्ति परीक्षा 2019 परीक्षा का पाठ्यक्रम कक्षा अनुसार ही होगा जोकि उन्हें प्राथम आने में सहयोग प्रदान करेगा | परीक्षा के प्रश्न-पत्र में सारे प्रश्न बहुविकल्पीय प्रश्न होंगे एवं प्रश्न-पत्र में कुल 100 प्रश्न दिए जायेंगे | इस छात्रव्रत्ति परीक्षा को देने क लिए अभयार्थियो को पहले पंजीकरण करना अनिवार्य होगा जोकि ऑनलाइन होगा जिसकी आखरी तारीख 15 जनवरी 2019 है |Distribution of Rai Publication Deskwork Scholarship Exam 2019:5th Class Topper Prize Money:- 4 Lakh Rupees8th Class Topper Prize Money:- 11 Lakh Rupees10th Class Topper Prize Money:- 51 Lakh Rupees12thClass Topper Prize Money:- 39 Lakh RupeesHow to fill Rai Publication Scholarship Form 2019 :Follow the above steps to register for the for Rai Publication Scholarship Examination 2019:Candidates can follow these below given instructions to apply for the scholarship exam of Rai Publication.The Rai Publication Scholarship application form is available in the news paper (Rajasthan Patrika.) You can also download it from this page. It also can be downloaded from the last page of your desk work.Application form is also given on the official website of Rai Publication: Rai Publication - Online Book Store for REET RPSC RAS SSC Constable Patwar 1st 2nd Grade TeacherNow fill the details correctly in the application form.Now send the application form to the head office of Rai Publication.Rai Publication Website Link Click HereHead Office Address of Rai PublicationShop No: -24 & 25, Bhagwan Das Market, Chaura Rasta, Jaipur, RajasthanPIN Code:- 302003Contact No.- 0141 232 1136Source : Rai Publication Scholarship Exam 2019
How do I fill out an NCC Scholarship form?
NCC (National Cadet Corps) is a voluntary organization which recruits cadets from high schools, colleges and universities all over India.To enroll yourself to it, Contact to your college/school office, they will give you forms and other necessary information about NCC. Every school/college have a person dedicated to NCC, He/She will guide you further.For NCC, your school/college should fulfill the requisite pre-conditions are as follows :(a) Availability of students for enrollment.(b) Availability of eligible teachers to be appointed as Associate NCC Officer(ANO). One ANO per school/college for Junior Division or Senior Division cadets.(c) Availability of parade ground, storeroom for NCC.(d) Short Range for firing in the vicinity.(e) Supplementing financial resources (in case of Govt aided institutions). Private institutions are required to bear entire expenditure of the State's share. Details will be available with nearest NCC Bn HQ.
How do I fill out 2016 ITR form?
First of all you must know about all of your sources of income. In Indian Income Tax Act there are multiple forms for different types of sources of Income. If you have only salary & other source of income you can fill ITR-1 by registering your PAN on e-Filing Home Page, Income Tax Department, Government of India after registration you have to login & select option fill ITR online in this case you have to select ITR-1 for salary, house property & other source income.if you have income from business & profession and not maintaining books & also not mandatory to prepare books & total turnover in business less than 1 Crores & want to show profit more than 8% & if you are a professional and not required to make books want to show profit more than 50% of receipts than you can use online quick e-filling form ITR-4S i.s. for presumptive business income.for other source of income there are several forms according to source of income download Excel utility or JAVA utility form e-Filing Home Page, Income Tax Department, Government of India fill & upload after login to your account.Prerequisite before E-filling.Last year return copy (if available)Bank Account number with IFSC Code.Form 16/16A (if Available)Saving Details / Deduction Slips LIC,PPF, etc.Interest Statement from Banks or OthersProfit & Loss Account, Balance Sheet, Tax Audit Report only if filling ITR-4, ITR-5, ITR-6, ITR-7.hope this will help you in case any query please let me know.
How do I fill out a CLAT 2019 application form?
Hi thereFirst of all, let me tell you some important points:CLAT 2019 has gone OFFLINE this yearBut the application forms for CLAT 2019 have to be filled ONLINEThe payment of the application fees also should be made onlineNow, kindly note the important dates:Note the details regarding the application fees:Here, if you want the Previous Year Question papers, Rs.500 would be added to the application fees.Apart from this, there would be bank transaction charges added to the application fees.The application fees is non-refundable.Note one important point here that before you fill the application form, check for your eligibility.To know the complete details of filling the application form along with other information like the eligibility - in terms of age, educational qualification, list of NLUs participating and the seats offered under each category, CLAT Reservation policies, CLAT exam pattern, marking scheme, syllabus, important documents required to be kept ready before filling the form, kindly go to the link below:How to fill CLAT 2019 Application form? Registration OPEN | All you need to knowTo know how to prepare for one of the very important section of CLAT exam, GK and Current Affairs, kindly go to the link below:How to prepare GK & Current Affairs for CLAT 2019To practice, daily MCQs on Current Affairs, kindly go to the link below:#CLAT2019 | #AILET2019 | #DULLB2019 | GK and Current Affairs Series: 5 in 10 Series: Day 12For any other queries, kindly write to us at email@example.com & Regards!
How do I fill out the NEET 2019 application form?
Expecting application form of NEET2019 will be same as that of NEET2018, follow the instructions-For Feb 2019 Exam:EventsDates (Announced)Release of application form-1st October 2018Application submission last date-31st October 2018Last date to pay the fee-Last week of October 2018Correction Window Open-1st week of November 2018Admit card available-1st week of January 2019Exam date-3rd February to 17th February 2019Answer key & OMR release-Within a week after examAnnouncement of result-1st week of March 2019Counselling begins-2nd week of June 2019For May 2019 Exam:EventsDates (Announced)Application form Release-2nd week of March 2019Application submission last date-2nd week of April 2019Last date to pay the fee-2nd week of April 2019Correction Window Open-3rd week of April 2019Admit card available-1st week of May 2019Exam date-12th May to 26th May 2019Answer key & OMR release-Within a week after examAnnouncement of result-1st week of June 2019Counselling begins-2nd week of June 2019NEET 2019 Application FormCandidates should fill the application form as per the instructions given in the information bulletin. Below we are providing NEET 2019 application form details:The application form will be issued through online mode only.No application will be entertained through offline mode.NEET UG registration 2019 will be commenced from the 1st October 2018 (Feb Exam) & second week of March 2018 (May Exam).Candidates should upload the scanned images of recent passport size photograph and signature.After filling the application form completely, a confirmation page will be generated. Download it.There will be no need to send the printed confirmation page to the board.Application Fee:General and OBC candidates will have to pay Rs. 1400/- as an application fee.The application fee for SC/ST and PH candidates will be Rs. 750/-.Fee payment can be done through credit/debit card, net banking, UPI and e-wallet.Service tax will also be applicable.CategoryApplication FeeGeneral/OBC-1400/-SC/ST/PH-750/-Step 1: Fill the Application FormGo the official portal of the conducting authority (Link will be given above).Click on "Apply Online" link.A candidate has to read all the instruction and then click on "Proceed to Apply Online NEET (UG) 2019".Step 1.1: New RegistrationFill the registration form carefully.Candidates have to fill their name, Mother's Name, Father's Name, Category, Date of Birth, Gender, Nationality, State of Eligibility (for 15% All India Quota), Mobile Number, Email ID, Aadhaar card number, etc.After filling all the details, two links will be given "Preview &Next" and "Reset".If candidate satisfied with the filled information, then they have to click on "Next".After clicking on Next Button, the information submitted by the candidate will be displayed on the screen. If information correct, click on "Next" button, otherwise go for "Back" button.Candidates may note down the registration number for further procedure.Now choose the strong password and re enter the password.Choose security question and feed answer.Enter the OTP would be sent to your mobile number.Submit the button.Step 1.2: Login & Application Form FillingLogin with your Registration Number and password.Fill personal details.Enter place of birth.Choose the medium of question paper.Choose examination centres.Fill permanent address.Fill correspondence address.Fill Details (qualification, occupation, annual income) of parents and guardians.Choose the option for dress code.Enter security pin & click on save & draft.Now click on preview and submit.Now, review your entries.Then. click on Final Submit.Step 2: Upload Photo and SignatureStep 2 for images upload will be appeared on screen.Now, click on link for Upload photo & signature.Upload the scanned images.Candidate should have scanned images of his latest Photograph (size of 10 Kb to 100 Kb.Signature(size of 3 Kb to 20 Kb) in JPEG format only.Step 3: Fee PaymentAfter uploading the images, candidate will automatically go to the link for fee payment.A candidate has to follow the instruction & submit the application fee.Choose the Bank for making payment.Go for Payment.Candidate can pay the fee through Debit/Credit Card/Net Banking/e-wallet (CSC).Step 4: Take the Printout of Confirmation PageAfter the fee payment, a candidate may take the printout of the confirmation page.Candidates may keep at least three copies of the confirmation page.Note:Must retain copy of the system generated Self Declaration in respect of candidates from J&K who have opted for seats under 15% All India Quota.IF any queries, feel free to comment..best of luck
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