Enhanced Selection of Candidates for Same-Day and Outpatient Total Knee Arthroplasty

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Reasons and Risk Factors for Same-Day Discharge Following Total Joint Arthroplasty: A Systematic Review

Background

Nowadays, emphasis is being given to same-day discharge (SDD) following total joint arthroplasty. Unfortunately, despite a high degree of success, there are instances of failed SDD. Therefore, we aim to conduct a systematic review to evaluate factors contributing to failed SDD after total joint arthroplasty.

Methods

Pubmed, Scopus, Cochrane, and Google Scholar were searched. The Newcastle Ottawa score was used for the quality assessment of selected studies. All the studies were evaluated through a narrative synthesis. A total of 11 studies evaluating 157,045 patients were selected. The mean age of patients was 62.5 years.

Results

Elderly patients (odds ratio [OR] 1.01 to OR 3.13), women (OR 1.63 to OR 2.87), non-white race (OR 1.31 to OR 2.19), hypertension (OR 1.11 to OR 1.41), diabetes (OR 1.25 to OR 4.06), cardiovascular diseases (OR 1.67 to OR 12.06), chronic obstructive pulmonary disease (OR 1.30 to OR 1.96), bleeding disorders (OR 1.32 to OR 1.52), obesity (OR 1.35 to OR 3.30), steroid use (OR 1.23 to OR 1.52), late procedure start time (OR 1.22 to OR 5.16), higher postoperative pain (OR 1.93 to OR 5.85), high American Society of Anesthesiologists score (OR 0.92 to OR 3.50) were major predictors of failed SDD.

Conclusions

Through our review, we highlighted that elderly patients, women, non-white race, hypertension, diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, bleeding disorders, obesity, steroid use, late procedure start time, higher postoperative pain, and high American Society of Anesthesiologists score were major predictors of a failed SDD. Many factors evaluated in our study were presented in one or two studies only; therefore, high-quality studies are required to supplement our findings.

Same-Day Discharge Does Not Increase Resource Utilization within One Year of Total Joint Arthroplasty

INTRODUCTION

While the safety of rapid recovery TJA is well established, less is known about its impact on postoperative care utilization patterns. We wished to examine whether same-day discharge-and its associated presumed reduction in hospital-based postoperative care and education-translates to the need for more postoperative support during the one-year recovery period.

MATERIALS AND METHODS

A retrospective review of 1,237 total hip arthroplasty (THA) and 1,710 total knee arthroplasty (TKA) patients who had 0- or 1-day length of stay (LOS) from January 2020 to October 2023 was conducted. The primary outcome was the number of follow-up visits with TJA providers at our institution during the one-year postoperative period. Secondary outcomes included 30-day emergency department (ED) returns, readmissions, one-year physical therapy utilization, and improvement in Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores at 6 to 12 months postoperatively. Bivariate and multivariable analyses were performed to compare outcomes between 0-day and 1-day LOS THA and TKA patients.

RESULTS

In both the THA and TKA populations, 0-day LOS patients were younger, had a lower average body mass index, were more likely to be White, men, and had an American Society of Anesthesiologists (ASA) score < 3 than 1-day LOS patients. After controlling for differences between groups, no significant differences in the number of one-year follow-up visits, physical therapy visits, ED returns, or readmissions were seen between 0 and 1-day THA or TKA patients. In TKA patients, 1-day LOS was associated with lower improvements in PROMIS-PF scores.

CONCLUSION

After risk adjustment, same-day discharge of THA and TKA patients did not result in increased resource utilization during the one-year postoperative period. In the setting of a coordinated joint arthroplasty program with nurse navigator support, same-day discharge can be safely performed without increasing the need for postoperative care in appropriately selected patients undergoing both THA and TKA.

Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center

Background: Total knee arthroplasty (TKA) is one of the most common inpatient and outpatient surgical procedures performed in the United States and is predicted to increase 401% by 2040. Surgical site infections (SSIs) at an incidence rate of approximately 2% are costly post-operative complications in TKA. Intra-operative surgical irrigants are used to decrease contaminating microbial bioburden within the surgical site to prevent SSI. The primary objective of this retrospective study was to evaluate the impact of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP; Next Science, Jacksonville, FL) on SSI incidence in primary TKA performed at an ambulatory surgery center (ASC). Patients and Methods: Primary TKAs were performed at a free-standing ASC. The novel surgical irrigant was used intra-operatively to rinse away debris and micro-organisms from the surgical site. Retrospective data collation included SSI rates, complication rates, and re-admissions due to SSI within 90 days of index surgery. Results: Among the 524 primary TKA surgeries, one peri-prosthetic joint infection (PJI) was diagnosed within 90 days of index surgery and one superficial incisional SSI was diagnosed within 30 days of index surgery. The PJI was attributed to an exogenously acquired upper respiratory tract infection rather than due to the failure of intra-operative regimes. The 0.19% PJI incidence rate indicated significant efficacy of XP in decreasing PJI. An overall complication rate of 7.82% was noted with none of the complications associated with usage of the novel surgical irrigant. Conclusions: XPERIENCE is a promising intra-operative antimicrobial irrigant that can be easily incorporated into a broader infection prevention strategy.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

PURPOSE

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

SOURCE

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

PRINCIPAL FINDINGS

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

CONCLUSION

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center

Background

Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial.

Purpose

We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC.

Methods

We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room.

Results

Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room.

Conclusion

In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

The five times sit-to-stand test predicts same-day discharge for outpatients undergoing total joint arthroplasty

PURPOSE

To examine whether a patient's pre-operatively administered five times sit-to-stand (FTSTS) test score, when used alone or when combined with previously established predictors, relates to same-day discharge (SDD) after total knee or hip arthroplasty.

METHODS

This study utilized a multivariate, retrospective, observational design. Electronic medical record data for included participants were used to analyze the relationship between the patient factors (including the novel FTSTS variable) and the SDD outcome. Univariate and multiple variable regression modeling was undertaken to understand the strength of the relationship between the independent variables with the dependent variable. Receiver operating curve (ROC) analysis was performed to determine the area under the curve (AUC) for the novel model. Cut score analysis was performed to establish the score which has the greatest utility for stratifying patients based upon their likelihood of achieving SDD.

RESULTS

All independent variables related to the SDD outcome with varying effect sizes. The dichotomized FTSTS score related to the SDD outcome with medium effect (Exp(B) = 2.56). The score of 13.6 s was established as the point where the test was most highly sensitive and specific. The combined model including all included patient characteristics had a classification accuracy of 64.7% and an area under the curve score of .724.

CONCLUSION

The FTSTS score had higher predictive accuracy than all other stand-alone patient characteristics for the SDD outcome.

Increasing the Volume of Outpatient Total Joint Arthroplasty Procedures: An Evaluation of a Novel Rapid Recovery Pathway Program Within an Academic Medical Center

Background

There has been a national trend toward shifting joint arthroplasty procedures to the outpatient setting. These cases are often performed in freestanding ambulatory surgery centers (ASCs), which are often not accessible to surgeons within academic practices.

Purposes

We sought to investigate a novel rapid recovery program used to transition arthroplasty patients to an outpatient-based care system within an academic medical center.

Methods

All patients undergoing hip or knee arthroplasty between November 2019 and April 2021 were retrospectively evaluated for their eligibility for a rapid recovery pathway through the Extended Stay Unit (ESU) based on clinical and social criteria. Once admitted, patients were evaluated for whether they were discharged from the unit or if hospital admission was necessary.

Results

Out of the 444 patients deemed candidates for the rapid recovery program, 188 patients were admitted to the ESU (42.3%); 18 (9.6%) required inpatient hospital admission, with the majority of these due to failing physical therapy (16; 88.9%). Of the ESU patients who were successfully discharged home, 55 (32.4%) were discharged on postoperative day (POD) 0 and 115 (67.6%) on POD 1 (<23 hours).

Conclusion

As total joint arthroplasties shift toward the outpatient setting, surgeons in academic institutions must employ strategies to increase their volume of patient candidates for outpatient procedures. Our retrospective study of prospectively collected data suggests the feasibility of creating a separate rapid recovery unit within the hospital that can be an effective method by which to eventually transition to the ASC setting.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty

BACKGROUND

The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA).

METHODS

Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."

RESULTS

Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics.

CONCLUSIONS

The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

Total knee arthroplasty in the outpatient vs inpatient settings: impact of site of care on early postoperative economic and clinical outcomes

BACKGROUND

The incidence of total knee arthroplasty (TKA) surgery performed in the outpatient setting has increased as a result of improved perioperative recovery protocols, bundled payments, and challenges brought by the coronavirus disease of 2019 (COVID-19) pandemic on health systems. This study evaluates early postoperative clinical and economic outcomes of patients treated in the inpatient vs outpatient setting using the Attune Knee System (AKS).

METHODS

Patients with an elective, primary TKA implanted with the AKS, from Q4 2015 to Q1 2021, were identified within the Premier Healthcare Database. The index was defined as the admission date for inpatient cases and the service day for outpatient procedures. Inpatient and outpatient cases were matched on patient characteristics. Outcomes included 90-day all-cause readmissions, 90-day knee reoperations, and index- and 90-day costs of care. Generalized linear models were used to evaluate outcomes (Reoperation: binomial distribution; costs: Gamma distribution with log link).

RESULTS

Before matching, 39,337 inpatient and 9,365 outpatient cases were identified, with greater comorbidities in the inpatient cohort. The outpatient cohort had a lower average Elixhauser Index (EI) compared to the inpatient cohort (1.94 (standard deviation (SD): 1.46) vs 2.17 (SD: 1.53), p < 0.001), and the rates for each individual comorbidities were also slightly lower in the outpatient compared to the inpatient cohorts. Post-match, 9,060 patients were retained in each cohort [mean age: ~ 67, EI = 1.9 (SD: 1.5), 40% male]. Post-match comorbidity rates were similar between inpatient and outpatient cohorts (outpatient EI: 1.94 (SD: 1.44)-inpatient EI: 1.96 (SD: 1.45), p = 0.3516): in both, 54.1% of patients had an EI between 1 and 2, and 5.1% had an EI ≥ 5. No differences were observed in 3-month reoperation rates (0.6% in outpatient, 0.7% in inpatient cohort). Index and post-index 90-day costs were lower in the outpatient vs inpatient cases [(savings for index-only costs: $2,295 (95% CI: $1,977-$2,614); 90 days post-index knee-related care only: $2,540 (95% CI: $2,205-$2,876); 90 days post-index all-cause care: $2,679 (95% CI: $2,322-$3,036)].

CONCLUSIONS

Compared to matched inpatient cases, outpatient TKA cases treated with AKS showed similar 90-day outcomes, at lower cost.

Spinal Anesthesia for Primary Hip and Knee Arthroplasty: Comparative Rates of Transient Neurological Symptoms and Urinary Retention using Lidocaine, Mepivacaine, and Bupivacaine

BACKGROUND

Short-acting spinal anesthetics enable rapid recovery hip and knee arthroplasty, however concerns with transient neurological symptoms (TNS) cause some to avoid using lidocaine. Post-operative urinary retention (POUR) is also a concern with spinal anesthesia. We sought to study the comparative rates of TNS and POUR between lidocaine, mepivacaine, and bupivacaine in a high-volume hip and knee arthroplasty setting.

METHODS

Data for 1,217 primary THA, TKA, and UKA cases were reviewed and grouped by spinal anesthetic agent (Lidocaine, Mepivacaine, or Bupivacaine). Of the 1,217 cases, utilization was 523 Lidocaine, 573 Mepivacaine, and 121 Bupivacaine. The incidence of TNS and POUR requiring catheterization was measured both by clinical evaluation as well as a questionnaire sent to patients 14 days postoperatively.

RESULTS

The overall rate of TNS was 8%. With the numbers available, there was no difference in rates of TNS between groups (6.9% Lidocaine, 9.2% Mepivacaine, and 4.1% Bupivacaine; P=0.297). There was no difference in rates of TNS or POUR between THA and TKA/UKA. Bupivacaine had a significantly higher rate of urinary retention (9.1%; P<0.001) than mepivacaine (2.8%) or lidocaine (1.5%).

CONCLUSIONS

This study showed no difference in the rate of TNS between the 3 common agents used in spinal anesthesia. Short-acting spinal anesthetics such as lidocaine and mepivacaine can lower the rate of POUR requiring catheterization helping to enable rapid recovery hip and knee arthroplasty.

The Effect of COVID-19 on Elective Total Knee Arthroplasty Utilization, Patient Comorbidity Burden, and Complications in the United States: A Nationwide Analysis

INTRODUCTION

Total knee arthroplasty (TKA) is one of the highest volume elective procedures done nationwide. Elective surgery was suspended because of the COVID-19 pandemic. The utilization trends, comparison of patient demographics, and postoperative outcomes in 2020 have yet to be evaluated substantially. We compared temporal trends in procedural volume, patient demographics, and postoperative complications of elective TKA in 2019 and 2020.

METHODS

Using a multicenter, nationwide representative sample, a retrospective query of the 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was conducted for patients undergoing elective TKA. Temporal trends in utilization, demographics, and length of stay were compared pre-COVID-19 (2019 to 2020Q1) with post-COVID-19 (2020Q2 to Q4). Postoperative outcomes were compared by calendar year (2019 versus 2020). Linear regression was used to evaluate changes in procedural volume over time. A significance threshold of P < 0.05 was used.

RESULTS

A total of 121,415 patients underwent elective TKA in 2019 (N = 72,002) and 2020 (N = 49,413), a 31.4% decline. The proportion of hospital-defined "outpatient" TKAs in 2020 was significantly greater than that in 2019 (41.5% versus 25.5%; P < 0.001). Elective TKA utilization declined by 65.1% in 2020Q2 and never returned to prepandemic baseline in 2020Q3 to Q4. The average length of stay was shorter in 2020 (1.56 versus 1.87 days; P < 0.001). The proportion of same-day discharge increased each quarter from 2019Q1 to Q4 (6.2% to 8.6%) to 2020Q1 to Q4 (8.7% to 17.1%). Total complication rates were similar in 2019 (4.84%) versus 2020 (4.75%); P = 0.430. The 30-day mortality (0.08% versus 0.07%; P = 0.858), revision surgery (1.0% versus 1.0%; P = 0.940), and readmission (2.8% versus 2.6%; P = 0.053) rates were no different between 2019 and 2020.

CONCLUSION

Elective TKA declined during the second quarter of 2020. A large proportion of surgeries were transitioned to outpatient with rates of same-day discharge increasing over the study period, despite no change in complication, mortality, and readmission rates. Patient outcomes were not compromised despite pandemic restrictions for elective surgery.

LEVEL OF EVIDENCE

Level III.

Same Day Joint Replacement Surgery: Patient Selection and Perioperative Management

Joint replacements are increasingly performed as outpatient surgeries. The push toward ambulatory joint arthroplasty is driven in part by the changing current health care economics and reimbursement models. Patients' selection and well-designed perioperative care pathways are critical for the success of these procedures. The rate of complications after outpatient joint arthroplasty is comparable to the rate of complications in the ambulatory setting. Patient education, adequate social support, multimodal analgesia, regional anesthesia are key ingredients to the ambulatory care pathway after joint arthroplasty. Motor sparing nerve blocks are often used in these settings. Implementation of the elements of fast protocols can result in overall improvement of outcome metrics for all patients undergoing joint arthroplasty, including reduced length of stay and increased rate of home discharge.

Predicting Total Knee Arthroplasty Outpatient Discharge: Surgeons versus Insurance Companies

BACKGROUND

Insurance companies are increasingly making unilateral determinations of admission status for primary total knee arthroplasty (TKA). These determinations may differ from those based on surgeon-derived criteria for outpatient knee replacement. The goal of this study is to determine if insurance company determinations of outpatient status are as reliable as surgeon-derived criteria in predicting outpatient discharge after TKA.

METHODS

We retrospectively reviewed 709 patients who were preoperatively authorized for outpatient TKA. Patients were stratified into 2 groups: "outpatient per surgeon" (appropriate for outpatient surgery per institutional protocols) or "outpatient per insurance" (appropriate for inpatient surgery per institutional protocols but denied inpatient status by insurance). The primary endpoint of this study was the conversion rate of outpatient to inpatient stay. Univariate logistic regression was performed to compare the odds of conversion to inpatient stay between outpatient per surgeon and outpatient per insurance procedures and other covariates.

RESULTS

The cohort included 434 outpatient per insurance (61.2%) and 275 outpatient per surgeon (38.8%) patients. Surgeons accurately predicted outpatients' discharge 92.0% of the time, while insurance companies did so 81.3% of time (P < .001). Outpatient per insurance procedures (odds ratio [OR] 2.20, P = .003) and body mass index >35 kg/m² (OR 1.82, P = .026) had higher odds of being converted to inpatient. Males had higher odds (OR 1.52, P < .001) of being discharged as outpatient.

CONCLUSION

Determining inpatient versus outpatient status is a complex decision involving both clinical and social factors. Surgeons accurately predicted outpatient discharge 92% of the time. Moreover, outpatient per insurance procedures were twice as likely to be converted to inpatient status. Therefore, insurance companies should leave deciding admission status up to both the patient and surgeon.

Safety and efficacy of outpatient hip and knee arthroplasty: a systematic review with meta-analysis

INTRODUCTION

This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways.

MATERIALS AND METHODS

An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways-following hip and/or (partial) knee arthroplasty-were included. Included studies were assigned-based on OJA definition-to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate.

RESULTS

A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41-0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02.

CONCLUSION

OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.

Causes and predictors of failed same-day home discharge following primary hip and knee total joint arthroplasty: a Canadian perspective

PURPOSE

Same-day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients.

METHODS

A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between 01 April 2019 and 31 March 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge.

RESULTS

The cohort consisted of 527 consecutive patients. 101 (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). 2 individual surgeons, later operative start time (OR 1.3; 95% CI, 1.15-1.55; p = 0.001), ASA class IV (OR 3.4; 95% CI, 1.4-8.2; p = 0.006) and undergoing a THA (OR 2.0; 95% CI, 1.2-3.1, p = 0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anaesthetic were found (p > 0.05). The 30-day readmission or 6-month reoperation were similar between groups (p > 0.05).

CONCLUSIONS

Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

The role of the lower extremity functional scale in predicting surgical outcomes for total joint arthroplasty patients

Background

The purpose of this study was to evaluate the relationship between lower extremity functional scale (LEFS) scores with postoperative functional outcomes for total joint arthroplasty (TJA) patients and to investigate the utility of this tool to create an individualized plan of care perioperatively.

Methods

Patients undergoing primary TJA at a single institution from 2016 to 2019 was retrospectively reviewed by a univariate analysis in terms of patient characteristics and outcomes across LEFS quartiles. Multivariate regression models were constructed to evaluate the association between the LEFS quartile and outcomes after controlling for confounding factors.

Results

A total of 1389 patients were included. All patients had a documented LEFS pre- and postoperatively with the last value documented at least 60 days to a maximum of 1 year after surgery. The following cutoffs for LEFS quartiles were observed: quartile 1 preoperative LEFS ≤27, quartile 2 ranges from 28 to 35, quartile 3 ranges from 36 to 43, and quartile 4 ≥ 44. Patients with a higher comorbidity burden and ASA score were more likely to have a lower LEFS. Higher levels of preoperative function were significantly associated with shorter LOS and higher rates of same day discharge, independent ambulation, mobility and activity scores, and rates of discharge home.

Conclusion

These findings suggest that LEFS is a useful tool for aiding clinical resource allocation decisions, and incorporation of the measure into existing predictive models may improve their accuracy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-021-00106-3.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty

Background:

Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA.

Methods:

This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results.

Results:

In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA.

Conclusions:

The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.

Level of Evidence: Level IV, case series.

Artificial neural network prediction of same-day discharge following primary total knee arthroplasty based on preoperative and intraoperative variables

AIMS

This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).

METHODS

Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.

RESULTS

The predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis.

CONCLUSION

Both ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols. Cite this article: Bone Joint J 2021;103-B(8):1358-1366.

Preoperative Predictors of Same-Day Discharge After Total Knee Arthroplasty

Background

In January 2020, The Centers for Medicare and Medicaid Services approved total knee arthroplasty (TKA) to be performed in ambulatory surgery centers (ASCs). This study aims to develop a predictive model for targeting appropriate patients for ASC-based TKA.

Methods

A retrospective review of 2266 patients (205 same-day discharge [SDD; 9.0%] and 2061 one-day length of stay [91.0%]) undergoing TKA at a regional medical center between July 2016 and September 2020 was conducted. Multiple logistic regression was used to evaluate predictors of SDD, as these patients represent those most likely to safely undergo TKA in an ASC.

Results

Controlling for other demographics and comorbidities, patients with the following characteristics were at reduced odds of SDD: increased age (odds ratio [OR] = 0.935, P < .001), body mass index ≥35 (OR = 0.491, P = .002), female (OR = 0.535, P < .001), nonwhite race (OR = 0.456, P = .003), primary hypertension (OR = 0.710, P = .032), ≥3 comorbidities (OR = 0.507, P = .002), American Society of Anesthesiologists score ≥3 (OR = 0.378, P < .001). The model was deemed to be of adequate fit using the Hosmer and Lemeshow test (χ² = 12.437, P = .112), and the area under the curve was found to be 0.773 indicating acceptable discrimination.

Conclusion

For patients undergoing primary TKA, increased age, body mass index ≥35, female gender, nonwhite race, primary hypertension, ≥3 comorbidities, and American Society of Anesthesiologists score ≥3 decrease the likelihood of SDD. A predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in identifying patients that are candidates for SDD or ASC-based TKA.

"Outpatient"-Same-calendar-day Discharge Hip and Knee Arthroplasty

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.

First Reported Series of Outpatient Total Knee Arthroplasty in the Middle East

Background

Outpatient total knee arthroplasty (TKA) is becoming more commonplace in the United States. Alternatively, the current practice in the Middle East involves an inpatient stay of 7-10 days in the hospital after TKA. This study reports the early results of the first reported series of outpatient TKA performed on patients in the Middle East and compares the clinical and functional outcomes with those of patients who underwent inpatient TKA.

Methods

Eighty-eight patients underwent TKA (inpatient: 44 and outpatient: 44) using the modified intervastus approach in 2 hospitals in the Middle East from 2017 to 2019. Clinical and functional outcomes were assessed by recording the Knee Injury and Osteoarthritis Outcome Score, visual analog scale (VAS) for pain, and knee range of motion (ROM) preoperatively, on the day of surgery, and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months.

Results

Two patients undergoing outpatient TKA had complications: one patient suffered a periprosthetic fracture on postoperative day 10 after a fall, and the other patient had drainage on postoperative day 5. No complications occurred in the inpatient TKA cohort. There were no significant differences observed in the VAS scores or knee ROM numbers recorded for inpatient and outpatient TKA groups at any of the follow-up periods. Overall, the Knee Injury and Osteoarthritis Outcome Score, VAS, and ROM significantly improved 6 months after surgery compared with preoperative values for both inpatient and outpatient TKA groups.

Conclusions

Outpatient TKA was safely implemented when compared with inpatient TKA, with satisfactory results. A total of 2 complications were seen in this study, which we believe are unrelated to the patient’s discharge status. The concept of outpatient TKA using the modified intervastus approach was very well accepted by the patients in this study and can potentially be applied safely elsewhere in the region.