Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting

A new dressing system for accelerating wound recovery after primary total knee arthroplasty: a feasibility study

PURPOSE

Currently, postoperative wound infection and poor healing of total knee arthroplasty have been perplexing both doctors and patients. We hereby innovatively invented a new dressing system to reduce the incidence of postoperative wound complications.

METHODS

We enrolled 100 patients who received primary unilateral total knee arthroplasty and then applied the new dressing system. The data collected included the number of dressing changes, postoperative hospital stay, Visual Analogue Scale score (VAS), the Knee Society Score (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), ASEPSIS scores, The Stony Brook Scar Evaluation Scale (SBSES), wound complications, dressing cost, the frequency of shower and satisfaction. Subsequently, a statistical analysis of the data was performed.

RESULTS

Our findings demonstrated the average number of postoperative dressing changes was 1.09 ± 0.38, and the average postoperative hospital stay was 3.72 ± 0.98 days. The average cost throughout a treatment cycle was 68.97 ± 12.54 US dollars. Collectively, the results of VAS, KSS, and KOOS revealed that the pain and function of patients were continuously improved. The results of the four indexes of the ASEPSIS score were 0, whereas the SBSES score was 3.58 ± 0.52 and 4.69 ± 0.46 at two weeks and one month after the operation, respectively. We observed no wound complications until one month after the operation. Remarkably, the satisfaction rate of the patients was 91.85 ± 4.99% one month after the operation.

CONCLUSION

In this study, we invented a new dressing system for surgical wounds after total knee arthroplasty and further confirmed its clinical feasibility and safety.

CHINESE CLINICAL TRIAL REGISTRY

ChiCTR2000033814, Registered 13/ June/2020.

Enhanced recovery after surgery in patients after hip and knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Enhanced recovery after surgery (ERAS) was characterized as patient-centered, evidence-based, multidisciplinary team-developed routes for a surgical speciality and institution to improve postoperative recovery and attenuate the surgical stress response. However, evidence of their effectiveness in osteoarthroplasty remains sparse. This study aimed to develop an ERAS standard and evaluate the significance of ERAS interventions for postoperative outcomes after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We searched Medline, Embase, Cochrane databases, and Clinicaltrials.gov for randomized controlled trials, cohort studies, and case-control studies until 24 February 2023. All relevant data were collected from studies meeting the inclusion criteria. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was the length of stay (LOS), postoperative complications, and readmission rate. The secondary outcomes included transfusion rate, mortality rate, visual analog score (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form 36 (SF-36) bodily pain (SF-36 BP), SF-36 physical function (SF-36 PF), oxford knee score, and range of motion (ROM).

RESULTS

A total of 47 studies involving 76 971 patients (ERAS group: 29 702, control group: 47 269) met the inclusion criteria and were included in the meta-analysis. The result showed that ERAS could significantly shorten the LOS (WMD = -2.65, P < .001), reduce transfusion rate (OR = 0.40, P < .001), and lower 30-day postoperative mortality (OR = 0.46, P = .01) without increasing postoperative complications or readmission rate. Apart from that, ERAS may decrease patients' VAS (WMD = -0.88, P = .01) while improving their ROM (WMD = 6.65, P = .004), SF-36 BP (WMD = 4.49, P < .001), and SF-36 PF (WMD = 3.64, P < .001) scores. However, there was no significant difference in WOMAC, oxford knee score between the ERAS and control groups.Furthermore, we determined that the following seven components of the ERAS program are highly advised: avoid bowel preparation, PONV prophylaxis, standardized anesthesia, use of local anesthetics for infiltration analgesia and nerve blocks, tranexamic acid, prevent hypothermia, and early mobilization.

CONCLUSION

Our meta-analysis suggested that the ERAS could significantly shorten the LOS, reduce transfusion rate, and lower 30-day postoperative mortality without increasing postoperative complications or readmission rate after THA and TKA. Meanwhile, ERAS could decrease the VAS of patients while improving their ROM, SF-36 BP, and SF-36 PF scores. Finally, we expect future studies to utilize the seven ERAS elements proposed in our meta-analysis to prevent increased readmission rate for patients with THA or TKA.

Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway

INTRODUCTION

There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.

OBJECTIVE

To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).

METHODS

A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.

RESULTS

Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASAII. The significantly associated factors to an increased length of stay are: age (P=.001), ASA scale (P=.04), day of surgery (P<.001), blood transfusion (P<.001), postoperative hemoglobin level at 48-72h (P<.001), the time of first postoperative mobilization to ambulate and climb stairs (P<.001), the need for analgesic rescues (P=.003), and the presence of postoperative nausea and vomiting (P=.008).

CONCLUSIONS

There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

BACKGROUND

Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.

METHODS

A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.

RESULTS

Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).

CONCLUSIONS

There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.

Initiation of a Comprehensive Early Discharge Program at a Veterans Affairs Hospital

INTRODUCTION

Early discharge protocols have become a major surgical paradigm, but this protocol is not routinely used in the Veteran Affairs (VA) system. The primary objective was to demonstrate the feasibility of a comprehensive joint program (CJP) protocol, including same-day discharge, at a VA hospital. Secondary objectives are to determine whether an increase in postoperative complications, increased readmissions, and increased ER visits compared with previous management protocols occur.

METHODS

A retrospective review of patients undergoing primary total joint arthroplasty conducted before the initiation of CJP was compared with patients undergoing primary total joint arthroplasty conducted after the initiation of CJP. The two cohorts were subdivided further into total knee arthroplasty (TKA) and total hip arthroplasty (THA). Patients' demographics, medical comorbidities, discharge disposition, length of stay (LOS), surgery information, 30-day and 90-day postoperative complications, surgical site infections, and emergency room visits were collected and assessed with paired t -tests.

RESULTS

A total of 200 control cases (101 TKA, 99 THA) were compared with 260 cases (165 TKA, 95 THA) in the CJP group. The mean LOS reduced from 4.38 days in the control group to 0.75 days in the CJP group ( P < 0.001), with 890 total inpatient days in the control group compared with just 200 total inpatient days with the CJP group. A total of 92 patients (34.5%) in the CJP group were discharged the same day compared with 0 in the control group ( P < 0.001). In the control group, 47.8% were discharged to rehabilitation centers compared with only 4.5% in the CJP group ( P < 0.001). The 30-day complication rate was reduced with CJP (5.6% vs. 10.3% control) ( P = 0.028). ER visits did not significantly change (8.9% control vs. 9.3% CJP; P = 0.77).

CONCLUSION

Overall LOS and complication rates were reduced with the CJP, exemplifying the viability of such a protocol in the VA system. In addition, we demonstrated no increased risks accompanied with early discharge to home. This initiative can be used to reduce healthcare dollars in VA healthcare system nationally.

Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

BACKGROUND

Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA.

METHODS

We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed.

RESULTS

Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS.

CONCLUSIONS

ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

Post-discharge patient-reported non-adherence to aspirin compared to enoxaparin for venous thromboembolism prophylaxis after hip or knee arthroplasty

BACKGROUND

Aspirin and enoxaparin are commonly used for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study was to compare non-adherence after discharge to aspirin or enoxaparin following THA or TKA.

METHODS

A subset of participants in the CRISTAL study were selected for participation. Additional inclusion criteria were no preoperative anticoagulant use and discharge from hospital before the prophylaxis period ended. The first four consecutive patients from each arm at each participating hospital were planned to be recruited (planned sample size n = 248). A patient-reported adherence questionnaire was completed by telephone at 36-41 days after THA and at 15-20 days after TKA. The primary outcome was non-adherence. Secondary outcomes were number of missed doses and the reasons for non-adherence.

RESULTS

There were 178 participants included from 15 sites, less than planned explained by early stopping of trial recruitment. There was no significant between-group difference in patient-reported non-adherence: 24% (17/71) for aspirin, 30% (32/107) for enoxaparin, odds ratio = 1.4 (95% CI 0.7-2.9). The mean number of missed doses was 2.5 for aspirin and 3.4 for enoxaparin (mean difference = 0.9 doses, 95% CI -1.2 to 3.1). For aspirin, the most commonly reported reason for non-adherence was forgotten doses and for enoxaparin it was clinician-recommended change.

CONCLUSIONS

Rates of non-adherence and the number of missing doses were similar for patients regardless of drug prescribed. The most common reasons for non-adherence were unrelated to the mode of administration.

The Role of a Seven-Day Physiotherapy Service in Reducing Length of Stay and Improving Cost-Effectiveness in Arthroplasty Surgery

Background Length of hospital stay post hip and knee arthroplasty is influenced by several factors, including gender, home circumstances and underlying diagnosis. Due to increasing demand for hip and knee arthroplasty, elective units, operating within already stressed healthcare systems, must identify methods of increasing efficiency and capacity. We sought to establish whether the lack of a seven-day inpatient physiotherapy service resulted in an increased hospital length of stay post primary hip and knee arthroplasty. Methods One hundred consecutive joint replacements (50 total hip replacements and 50 total knee replacements (TKRs)), performed in our institution from January to February 2020, were assessed. The length of stay for the cohort was analysed, and delays to discharge were identified. T-test was used to analyse the difference in length of stay based on the day of the week the surgery was performed. Results The mean length of stay for all primary hip and knee arthroplasties was 3.42 (standard deviation (SD): 1.62) days. Hip and knee arthroplasties performed on a Thursday or Friday had a significantly higher average length of stay than those performed on Monday, Tuesday or Wednesday (3.89 versus 3.02, p=0.006). We calculated that operating a six-day versus seven-day physiotherapy service in our unit cost 318 bed days per year equating to €986,535. Conclusion Length of stay post total hip and knee arthroplasty in our unit is significantly affected by the day of the week that surgery is performed. Elective orthopaedic units should consider all means of maximising efficiency and lowering costs given the future challenges in service provision.

Increased Patient-Level Payment After Removal of Total Knee Arthroplasty From the Inpatient-Only List

BACKGROUND

In January 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient Only (IPO) list. This study aimed to compare patient-level payments in TKA cases with a length of stay (LOS) <2 midnights before and after removal of TKA from IPO list.

METHODS

In this retrospective cohort study, all Medicare patients who received a primary elective TKA from 2016-2019 with a LOS <2 midnights at an academic tertiary center were identified. Total and itemized charges and patient-level payments were compared between eligible TKA cases performed in 2016-2017 and those in 2018-2019. There were 351 eligible TKA cases identified: 151 in 2016-2017 and 200 in 2018-2019.

RESULTS

The percentage of patients making any out-of-pocket payment increased in 2018-2019 from 2016-2017 (51.0% versus 10.6%), as did median patient-level payment ($7.30 [range, $0.00-$3,389] versus $0.00 [range, $0.00-$1,248], P < .001 for both). A greater proportion of patients in 2018-2019 paid $1-$50 than in 2016-2017 (37.5% versus 1.3%, P < .001) with no change in the proportion of patients who made payments >$50. Total charges were less in 2018-2019 than in 2016-2017 (P = .001). Charges for drugs, laboratory tests, admissions/floor, and therapies decreased in 2018-2019, whereas charges for the operating room and radiology increased (P < .001 for all).

CONCLUSION

Patients receiving outpatient TKA in 2018-2019 were more likely to have out-of-pocket payments than patients with comparable hospital stay who were designated as inpatients, although most of these payments were less than $50.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

External Fixation Characteristics Drive Cost of Care for High-Energy Tibial Plateau Fractures

OBJECTIVE

To determine the total cost for a 30-day episode of care for high-energy tibial plateau fractures and the aspects of care associated with total cost.

DESIGN

Time-driven activity-based costing analysis.

SETTING

One Level 1 adult trauma center.

PATIENTS

One hundred twenty-one patients with isolated, bicondylar tibial plateau fractures undergoing staged treatment were reviewed.

PRIMARY OUTCOME

Total cost.

RESULTS

A total of 85 patients were included and most sustained Schatzker VI fractures (n = 66, 77%). All patients were treated with biplanar external fixation before definitive fixation. A total of 26 patients (31%) were discharged to skilled nursing facilities, and 37 patients (43%) were not discharged between procedures. Total cost for a 30-day episode of care was $22,113 ± 4056. External fixation components ($5952, 26.9%), length of hospital stay ($5606, 25.4%), discharge to skilled nursing facility (SNF) ($3061, 13.8%), and definitive fixation implants ($2968, 13.4%) contributed to the total cost. The following were associated with total cost: patient discharged to SNFs (P < 0.001), patient remaining inpatient after external fixation (P < 0.001), days of admission for open reduction internal fixation (ORIF) (P = 0.005), days spent with external fixation (P < 0.001), days in a SNF after ORIF (P < 0.001), and external fixation component cost (P < 0.001).

CONCLUSIONS

External fixation component selection is the largest contributor to cost of a 30-day episode of care for high-energy bicondylar tibial plateau fractures. Reduction in cost variability may be possible through thoughtful use of external fixation components and care pathways.

LEVEL OF EVIDENCE

Economic analyses Level IV. See Instructions for Authors for a complete description of levels of evidence.

Same-day discharge to home is feasible and safe in up to 75% of unselected total hip and knee arthroplasty

PURPOSE

Though numerous studies highlighted benefits of ambulatory total joint arthroplasty (TJA), most had selected patients with age and comorbidities thresholds. We aimed to report proportions of unselected TJAs that could be scheduled for and operated in ambulatory settings, and to determine factors that hinder same-day discharge (SDD).

METHODS

We studied 1100 consecutive primary TJAs (644 THAs and 456 TKAs) that were prepared following a multidisciplinary protocol for patient education and logistical preparation. Data were stratified for THA vs TKA and for success vs failure of SDD to home and multivariable analysis was performed to determine factors associated with failure of scheduled SDD to home.

RESULTS

In total, 860 (78.2%) were scheduled for ambulatory surgery, but only 819 (74.5%) achieved SDD to home; 240 (21.8%) were scheduled for non-ambulatory surgery, but 103 (9.3%) achieved SDD to rehabilitation centre. Re-operations were required in 9 (1.0%) ambulatory TJAs vs 2 (0.8%) non-ambulatory TJAs (p = 0.769), while revisions were required in 13 (1.5%) ambulatory TJAs vs 1 (0.4%) non-ambulatory TJAs (p = 0.181). Multivariable analysis confirmed that failure of SDD to home was greater for women (OR 2.59; p = 0.011) and THA (vs TKA, OR 2.41; p = 0.023).

CONCLUSION

With appropriate education and preparation, 75% of unselected primary hip and knee arthroplasties achieved SDD to home without compromising risks of complications, re-operations, or revisions. A further 9% achieved SDD to rehabilitation centre, implying that 84% of patients did not require overnight stay. These findings suggest that ambulatory surgery is feasible and safe to implement in most unselected lower limb arthroplasties.

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital

Rapid recovery protocols (RRPs) for total joint arthroplasty (TJA) can reduce hospital length of stay (LOS) and improve patient care in select cohorts; however, there is limited literature regarding their utility in marginalized patient populations. This report aimed to evaluate the outcomes of an institutional RRP for TJA at a safety net hospital.

Preoperative Home Care Can Be One of the Factors Affecting the Length of Hospital Stay in Patients Undergoing Total Hip Arthroplasty

PURPOSE

To assess the importance of home nursing care on the functional outcome, quality of life, and length of stay of patients who underwent total hip arthroplasty.

METHODS

This was a retrospective cross-sectional study including patients who underwent surgery from February 2011 to December 2016. Patients were analyzed in two groups: with home care (received nursing care) and without home care. The analyzed outcomes were quality of life, functional outcome, and length of hospital stay. Total follow-up with questionnaires was 24 months.

RESULTS

A total of 244 patients (143 with home care and 101 without home care) were analyzed. No significant differences were found regarding the mean age (p = 0.125), gender distribution (p = 0.449) and BMI (p = 0.548) between the two groups. There was also no significant difference regarding functional outcome (p = 0.107) and quality of life (p = 0.848), measured by validated tools. However, the median of length of hospital stays in the home care group was lower in 1 day compared to without home care group (p < 0.001).

CONCLUSION

The home nursing care did not influence the functional outcome or quality of life of the patients, but there was a decrease in the length of hospital stay in the group that received preoperative nursing care.

Early Discharge After Total Hip Arthroplasty at an Urban Tertiary Care Safety Net Hospital: A 2-Year Retrospective Cohort Study

INTRODUCTION

Previous studies have shown that shorter inpatient stays after total hip arthroplasty (THA) are safe and effective for select patient populations with limited medical comorbidity and perioperative risk. The purpose of our study was to compare the postoperative complications because they relate to the length of hospital stay at a safety net hospital in the urban area of the United States.

METHODS

We retrospectively reviewed the medical records of 236 patients who underwent primary THA in 2017 at an urban safety net hospital. We collected data on demographics, medical comorbidities, and surgical admission information. Patients were categorized as "early discharge" if they were discharged on postoperative day 0 to 1 and "standard discharge" if they were discharged on postoperative day 2 to 5. The outcomes of interest were 90-day and 2-year postoperative complications, emergency department visit, readmissions, and revision surgeries. Data were analyzed using t-test or chi-square test for univariate analysis and linear logistic regression for controlled analysis.

RESULTS

Compared with the standard discharge group, there were markedly more male patients in the early discharge group (44.5% versus 80%). Early discharge patients were markedly younger (53.3 versus 59.5 years old), more likely to be White/non-Hispanic (64.4% versus 42.4%) and less likely to have heart disease and diabetes (2.2% versus 15.2% and 2.2% versus 19.9%, respectively). With adjustment for these potential confounders, no notable difference was observed in all-type complications, emergency department visits, readmission, or revision surgery between the two groups.

DISCUSSION

This study confirmed that early discharge after THA is as safe as standard discharge in a safety net hospital with appropriate preoperative risk screening. Increased perioperative counseling and optimization of social and medical risk factors mitigated possible risk factors for increased length of stay and surgical complication.

Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population

BACKGROUND

Total joint arthroplasty is the most common elective orthopedic procedure in the Veterans Affairs hospital system. In 2019, physical medicine and rehabilitation began screening patients before surgery to select candidates for direct transfer to acute rehab after surgery. The primary outcome of this study was to demonstrate that the accelerated program was successful in decreasing inpatient costs and length of stay (LOS). The secondary outcome was to show that there was no increase in complication, reoperation, and readmission rates.

METHODS

A retrospective review of total joint arthroplasty patients was conducted with three cohorts: 1) control (n = 193), 2) transfer to rehab orders on postop day #1 (n = 178), and 3) direct transfers to rehab (n = 173). To assess for demographic disparities between cohorts, multiple analysis of variance tests followed by a Bonferroni P-value correction were used. Differences between test groups regarding primary outcomes were assessed with analysis of variance tests followed by pairwise t-tests with Bonferroni P-value corrections.

RESULTS

There were no significant differences between the cohort demographics or comorbidities. The mean total LOS decreased from 7.0 days in the first cohort, to 6.9 in the second, and 6.0 in the third (P = .00034). The mean decrease in cost per patient was $14,006 between cohorts 1 and 3, equating to over $5.6 million in savings annually. There was no significant change in preintervention and postintervention short-term complications (P = .295).

CONCLUSIONS

Significant cost savings and decrease in total LOS was observed. In the current health care climate focused on value-based care, a similar intervention could be applied nationwide to improve Veterans Affair services.

Rapid Recovery Is Feasible for Aseptic Revision Total Knee Arthroplasty at an Academic Medical Center

Background

We reviewed the results of a primary total knee arthroplasty (TKA) rapid recovery care pathway applied to patients undergoing aseptic revision TKA. We sought to determine (1) the frequency of postoperative day (POD) 1 discharge, (2) the risk of adverse events, and (3) patient characteristics or surgical factors associated with failure to discharge on POD 1.

Methods

The source population was revision TKAs performed by a single surgeon at an academic medical center from 2016 to 2019 (n = 94). A primary TKA rapid recovery care pathway was applied to all patients who underwent aseptic revision TKA involving both femoral and tibial components (n = 33). Patients discharged on POD 1 (n = 21) were compared with those discharged on POD 2 or later (n = 12).

Results

The study cohort was 70% women, 12% under-represented minorities, and 70% government insured. Patients each had an average of 5 comorbidities. The average length of stay was 1.7 days, with 64% of patients discharged on POD 1. Ninety-seven percent of patients were discharged home. Although 18% of patients presented to the emergency room (ER) after discharge, there was no increased risk of readmission (P = .9336) or return to the ER (P = .9849) with POD 1 discharge. The LOS was unaffected by patient characteristics or complexity of surgical reconstruction.

Conclusions

Using a rapid recovery care pathway for aseptic revision TKA is feasible at an academic medical center. All patients may be considered for this pathway. Close postoperative monitoring is essential to minimizing ER visits, which are not uncommon.

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

BACKGROUND

There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA.

METHODS

Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed.

RESULTS

In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases.

CONCLUSION

Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

Risk factors for femoral fracture in lateral decubitus direct anterior approach total hip arthroplasty using conventional stems: a retrospective analysis

OBJECTIVE

To provide guidelines for surgery and reduce the incidence of fracture, this study analyzed the relationship between femoral fracture and related factors in direct anterior approach (DAA) total hip arthroplasty (THA) in the lateral decubitus position.

METHOD

A retrospective series of 273 consecutive patients who underwent THA with the DAA in the lateral decubitus position was analyzed. Each surgery was performed by the same surgeon with a conventional operation bed and femoral stem. The correlations between the incidence of fracture and sex, age, body mass index (BMI), height, osteoporosis, the anterior superior iliac spine-greater trochanter distance (ASIS-GTD), and hip joint disease were analyzed by univariate analysis and logistic regression analysis.

RESULTS

Among all hip arthroplasty procedures, 35 hips had femoral fractures, including 30 greater trochanter fractures, 4 proximal femoral splits, and 1 femoral perforation. The incidence of fracture was 12.82%. Univariate analysis showed no significant difference in the incidence of fracture by sex, BMI, or age. However, osteoporosis caused an increase in the incidence of fracture, while the incidence of fracture decreased as height and the ASIS-GTD increased. The incidence of femoral neck fracture was lower in cases of osteonecrosis of the femoral head than in cases of other diseases. Logistic regression showed a significant correlation between osteoporosis, the ASIS-GTD, and fractures. Patients with osteoporosis had a high possibility of fracture (OR = 2.414); the possibility of fracture decreased with increasing ASIS-GTD (OR = 0.938).

CONCLUSION

Lateral decubitus DAA THA can be successfully performed using a conventional operation bed and stem, effectively saving medical resources. Osteoporosis and a shorter ASIS-GTD were independent risk factors for femoral fracture.

More Patients Are Being Discharged Home After Total Knee Arthroplasty, However Rates Vary Between Large Databases

BACKGROUND

There have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications.

METHODS

Patients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed.

RESULTS

In total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001).

CONCLUSION

Patients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.

Improved patient reported outcomes with functional articulating spacers in two-stage revision of the infected hip

BACKGROUND

Two-stage revision arthroplasty with an antibiotic-loaded spacer is the treatment of choice in chronically infected total hip arthroplasties. Interval spacers can be functional articulating or prefabricated. Functional results of these spacers have scarcely been reported.

AIM

To compare retrospectively the patient reported outcome and infection eradication rate after two-stage revision arthroplasty of the hip with the use of a functional articulating or prefabricated spacer. 

METHODS

All patients with two-stage revision of a hip prosthesis at our hospital between 2003 and 2016 were included in this retrospective cohort study. Patients were divided into two groups; patients treated with a functional articulating spacer or with a prefabricated spacer. Patients completed the Hip Osteoarthritis Outcome Score and the EQ-5D-3L (EQ-5D) and the EQ-5D quality of life thermometer (EQ-VAS) scores. Primary outcomes were patient reported outcome and infection eradication after two-stage revision. The results of both groups were compared to the patient acceptable symptom state for primary arthroplasty of the hip. Secondary outcomes were complications during spacer treatment and at final follow-up. Descriptive statistics, mean and range are used to represent the demographics of the patients. For numerical variables, students’ t-tests were used to assess the level of significance for differences between the groups, with 95% confidence intervals; for binary outcome, we used Fisher’s exact test.

RESULTS

We consecutively treated 55 patients with a prefabricated spacer and 15 patients with a functional articulating spacer of the hip. The infection eradication rates for functional articulating and prefabricated spacers were 93% and 78%, respectively (P > 0.05). With respect to the functional outcome, the Hip Osteoarthritis Outcome Score (HOOS) and its subscores (all P < 0.01), the EQ-5D (P < 0.01) and the EQ-VAS scores (P < 0.05) were all significantly better for patients successfully treated with a functional articulating spacer. More patients in the functional articulating spacer group reached the patient acceptable symptom state for the HOOS pain, HOOS quality of life and EQ-VAS. The number of patients with a spacer dislocation was not significantly different for the functional articulating or prefabricated spacer group (P > 0.05). However, the number of dislocations per patient experiencing a dislocation was significantly higher for patients with a prefabricated spacer (P < 0.01).

CONCLUSION

Functional articulating spacers lead to improved patient reported functional outcome and less perioperative complications after two-stage revision arthroplasty of an infected total hip prosthesis, while maintaining a similar infection eradication rate compared to prefabricated spacers.

Ideal intraarticular application dose of tranexamic acid in primary total knee arthroplasty: a prospective, randomized and controlled study

Background

Combined use of tranexamic acid (TXA) via intravenous (IV) and intraarticular (IA) routes is more effective in reducing blood loss than any single route in primary total knee arthroplasty (TKA), but the optimal dose of topical administration remains controversial. The aim of this study was to evaluate the efficacy and safety of different combined administration strategies and to determine an ideal IA application dose of TXA.

Methods

A total of 180 patients who underwent primary TKA were randomized to four groups (groups A/B/C/D) with the same single IV dose of 1 g TXA preoperatively and four different IA doses after wound closure: group A (0 g), group B (1 g), group C (2 g), and group D (4 g). The primary outcome measures included wound blood drainage, hemoglobin (Hb) concentration, and blood transfusion. The secondary outcome measures included wound complications, deep vein thrombosis (DVT) and symptomatic pulmonary embolism (PE).

Results

A total of 165 patients finished at least 3 months of follow-up visits. The amount of 48-hour blood drainage and calculated total blood loss in four groups decreased with the increased dose of TXA injected via IA route, and no difference was observed between groups C and D (P=0.6237 and P=0.9923, respectively). Hb was significantly higher in groups C and D than in groups A and B at postoperative day 1, 3 and 7, respectively (P<0.0001). Hb in group A was significantly lower than that in groups C and D at 1 month after surgery, whereas no intergroup difference was found in other groups. No intergroup difference was observed regarding DVT, PE or wound complications.

Conclusions

The topical injection of 2 g TXA may have reached the “ceiling effect” of local use. A preoperative IV dose of 1 g TXA combined with an IA dose of 2 g TXA could be an optimal combination regimen.

Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

Background

After implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC).

Study Design

Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit.

Results

Of 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC.

Conclusions

Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.

Spinal Anesthesia Using Chloroprocaine is Safe, Effective, and Facilitates Earlier Discharge in Selected Fast-track Total Hip Arthroplasty

BACKGROUND

Spinal anesthetic choice plays an underappreciated role in total hip arthroplasty (THA). Chloroprocaine, a short-acting local anesthetic, has been limited to short-duration ambulatory procedures and has not been studied in THA. We compare perioperative outcomes of patients undergoing fast-track THA using chloroprocaine spinal anesthesia with those who have surgery with a longer-acting agent (bupivacaine).

METHODS

A total of 143 THAs performed under spinal anesthesia by 3 arthroplasty surgeons between November 2018 and July 2019 were retrospectively reviewed. Patients receiving chloroprocaine were matched 1:1 by demographics to patients receiving bupivacaine. Ultimately, 74 patients were included (37 chloroprocaine and 37 bupivacaine). The primary outcome was hospital length of stay (LOS). Other perioperative outcomes were also evaluated.

RESULTS

A total of 37 patients (50%) received chloroprocaine (60 mg), whereas 37 (50%) received bupivacaine (median 10 mg, range 8-15 mg). Among the matched groups, chloroprocaine use was associated with shorter hospital LOS (0.9 vs 1.2 days; P = .03), shorter operative time (68.2 vs 83.6 minutes, P = .03), lower estimated blood loss (184.7 vs 218.9 mL, P = .02), shorter postanesthesia care unit LOS (139.4 vs 194.9 minutes; P = .04), and less intraoperative hypotension (59.5% vs 83.8%, P = .02). Patients receiving chloroprocaine were also more commonly discharged home (100% vs 89.2%; P = .04).

CONCLUSION

Chloroprocaine is a safe and reliable option for patients to mobilize rapidly and leave the hospital sooner after THA. Compared with bupivacaine, it is associated with shorter hospital LOS and higher likelihood for discharge to home.

Outpatient vs. inpatient hip arthroplasty: a matched case-control study on a 90-day complication rate and 2-year patient-reported outcomes

BACKGROUND

The transition to outpatient-based surgery is a major development occurring in recent years in the field of total hip arthroplasty (THA). The effect of this transition on patient-reported outcomes (PROs) is still not well established. The purpose of the current study was to compare patients undergoing inpatient THA (iTHA) to patients undergoing outpatient THA (oTHA) regarding (1) perioperative variables including surgical time, blood loss, and length of stay (2) 90-day complication rates and unplanned emergency room or office visits (3) 2-year PROs including modified Harris hip score (mHHS), Harris hip score (HHS), forgotten joint score (FJS), pain, and satisfaction, as well as the quality of live measures.

METHODS

The American Hip Institute registry was analyzed for patients undergoing THA between July 2014 and April 2016. The first 100 patients undergoing oTHA were selected and matched to 100 patients undergoing iTHA via propensity matching based on the following variables: age, sex, body mass index (BMI), Charlson comorbidity index (CCI), and smoking status. The primary outcomes were PROs at 2 years post-operatively. The secondary outcomes were perioperative surgical variables, 90-day complication rates, and unplanned emergency and clinic visits.

RESULTS

After exclusions, 91 patients remained in each group and were compared. The oTHA group showed improved 2-year PROs with regard to mHHS (91.5 vs. 86.2; P = 0.02), HHS (92.3 vs. 87.4; P = 0.02), and pain (1.0 vs. 1.5; P = 0.04). The oTHA group had an average length of stay of 6.8 h compared to 43.2 h for the iTHA group (P < 0.001). There were no significant differences between the groups regarding readmissions, emergency room visits, and unplanned clinic visits. Complications and revision rates were similar in both groups.

CONCLUSION

In appropriately selected, younger patients, oTHA can achieve improved postoperative 2-year PROs compared to iTHA. We found no differences regarding postoperative short-term complications or 2-year revision rates, and no differences in unplanned office visits or readmissions.

LEVEL OF EVIDENCE

Prognostic level 3.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital

Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.

Methods

In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.

Results

In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).

Conclusions

Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System

BACKGROUND

The number of outpatient mastectomies, with and without reconstruction, has increased nationwide. In well-selected patient populations, same-day surgery for mastectomy is a safe option. A pilot project was initiated within the Kaiser Permanente Northern California healthcare system to facilitate surgical home recovery (SHR) for mastectomy patients, including patients undergoing implant-based reconstruction and bilateral mastectomies.

METHODS

Surgical home recovery for mastectomy patients was implemented in October 2017. Specific measures in this initiative included management of patient expectations at initial consultation, education about postoperative home care, multimodality pain management, and timely post-discharge follow-up. All patients undergoing mastectomy were included, except those undergoing autologous tissue reconstructions. After a 6-month implementation period, rate of same day discharge over 6 months was compared before and after the SHR initiative. We also compared emergency department (ED) visits, reoperations, and readmissions within 7 days.

RESULTS

Twenty-one medical centers participated in this initiative. Before implementing SHR, 164 of the 717 (23%) mastectomies were outpatient procedures, compared with 403 of the 663 (61%) after the implementation period. Although the rate of outpatient mastectomy increased significantly, there were no statistically significant differences in ED visits (5.2% vs. 5.1%, p = 0.98), reoperation (3.5% vs. 3.5%, p = 0.99), or readmission rates (1.4% vs. 2.7%, p = 0.08).

CONCLUSIONS

By implementing standard expectations and sharing best practices, there was a significant increase in the rate of home recovery for mastectomy without compromising quality of patient care. The success of this pilot program supports SHR for mastectomy.