Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes, Complications, and Healthcare Utilizations (2010 to 2020)

Risk Factors and Incidence of 30-Day Readmission Following Outpatient Total Knee Arthroplasty

BACKGROUND

Reflecting advancements in surgical techniques and postoperative care, total knee arthroplasty (TKA) is being performed increasingly as an outpatient procedure. This study aimed to report the frequency and timing of unplanned readmission after outpatient TKA with updated data, identify risk factors for readmission after outpatient TKA, and identify common causes for readmission after outpatient TKA with a much larger cohort compared to previous studies.

METHODS

This study retrospectively analyzed data from 31,347 patients who underwent outpatient TKAs between 2012 and 2021. Adverse events and unplanned readmissions were identified. Timing and reason for readmission were recorded. Statistical analysis involved multivariate logistic regression to identify patient risk factors for readmission.

RESULTS

Following surgery, 1.86% of cases reported an unplanned readmission within 30 days. Multivariate analysis demonstrated that age (odds ratio (OR): 1.042; P < 0.001), body mass index (OR: 1.023; P = 0.002), operative time (OR: 1.003; P = 0.017), congestive heart failure (OR: 3.079; P < 0.001), chronic obstructive pulmonary disease (OR: 2.577; P < 0.001), bleeding disorders (OR: 1.706; P = 0.025), hypertension (1.436; P < 0.001), and partially dependent functional status (OR: 2.486; P = 0.036) significantly increased the risk of 30-day readmission. Reasons unrelated to the surgical site contributed the most to readmission at 68.3%, while reasons related to the surgical site made up 27.3%, followed by knee-related complaints (4.4%). The most common days on which readmissions occurred were postoperative days two, four, and one.

CONCLUSIONS

Our analysis revealed a low readmission risk (1.86%) after outpatient TKA. Readmission rates were found to decrease over the observed time, despite a dramatic increase in outpatient cases. The most common reason for 30-day readmission was an organ or space surgical site infection. Identified risk factors for readmission highlight areas for targeted mitigation to enhance patient outcomes and healthcare efficiency.

How to Manage Intraoperative Complications During Primary Total Knee Arthroplasty

BACKGROUND

Intraoperative complications are ideally prevented altogether, but are nevertheless an inherent and unavoidable risk in primary total knee arthroplasty (TKA).

METHODS

/Results: This article provides a review of a symposium on primary TKA intraoperative complications that was presented at the American Association of Hip and Knee Surgeons (AAHKS) 2024 Annual Meeting. The following four intraoperative complications were reviewed: 1) medial collateral ligament (MCL) injury; 2) neurovascular injury; 3) extensor mechanism injury; and 4) periprosthetic fracture.

CONCLUSION

As the nationwide and per-surgeon volume of primary TKA continues to increase, it is imperative for arthroplasty surgeons to be prepared to prevent, identify, and manage intraoperative complications during primary TKA.

Inpatient Revision Total Knee Arthroplasty Has a Higher Risk of Early Complications: A Propensity Score-Matched Analysis with Outpatient Revision Total Knee Arthroplasty

BACKGROUND

With the rise in outpatient elective surgery, the safety of revision total knee arthroplasty (TKA) as an outpatient procedure has been questioned. This study compared surgical outcomes and complications of inpatient versus outpatient revision TKA using a large national database.

METHODS

The database was queried for patients who underwent outpatient and inpatient revision TKA. Groups were propensity-matched by age, sex, one or two-component revision, and the Elixhauser Comorbidity Index, resulting in 7,728 patients per group. Outcome measures included 2-year re-revision, 90-day hospital readmission, manipulation under anesthesia, and 6-month medical complications. Queries were based on Current Procedural Terminology and International Classification of Diseases codes. Binomial logistic regression was used to determine predictors of failure.

RESULTS

Hospital readmissions were higher in the inpatient revision TKA group (P < 0.001). The inpatient group had higher rates of blood transfusion (odds ratio (OR): 2.0 (1.6 to 2.5) P < 0.001), deep vein thrombosis (OR: 1.8 (1.1 to 2.8) P = 0.02), pulmonary embolism (OR: 2.7 (1.7 to 4.2) P < 0.001), acute kidney injury (OR: 1.5 (1.3 to 1.8) P < 0.001), and periprosthetic joint infection (OR: 1.5 (1.4 to 1.7), P < 0.001). Independent predictors of failure in the inpatient group were age (P < 0.001), two-component revision (OR: 3.7 (3.1 to 4.4) P < 0.001), and infection (OR: 3.9 (3.3 to 4.7) P < 0.001) and in the outpatient group were age (P < 0.001), Elixhauser Comorbidity Index (P = 0.03), two-component revision (OR: 4.2 (3.6 to 5.0) P < 0.001), and infection (OR: 3.9 (3.2 to 4.7) P < 0.001).

CONCLUSIONS

Outpatient revision TKA did not carry a higher risk of medical complications, hospital readmissions, or re-revision. Inpatient revision TKA had a higher incidence of medical complications. While inpatient care remains important for patients with complex medical conditions, outpatient revision TKA is a safe and effective option in appropriately-selected patients.

When Is It Safe for Patients to Air Travel After Total Hip and Knee Arthroplasty: A Comprehensive Review

» Despite many patients traveling by air for total hip arthroplasty (THA) and total knee arthroplasty (TKA), there are limited data to guide recommendations for air travel after these procedures.» It is unknown whether the timing of postoperative air travel contributes to the risk of developing venous thromboembolism (VTE) after THA and TKA.» The existing limited data do not suggest a difference in VTE risk between those who did and did not travel by air after THA and TKA surgery, mostly within 7 days.» As more patients travel by air seeking THA and TKA, there is an increasing need for a thorough evaluation of associated risks. This assessment should account for patient-specific risk factors, duration of air travel, and the timing of flights in relation to the postoperative period to ensure optimal safety and outcomes.» There is no consensus on the ideal VTE prophylaxis for patients who travel by air after THA and TKA. However, long-haul flights (>4 hours) are associated with a higher VTE risk and are likely to require stronger prophylactic measures.» Some airlines and regulatory agencies may enforce regulations for passengers who travel by air soon after THA and TKA. Patients may be asked to present proof of medical clearance from the treating surgeon before boarding the airplane in addition to being on appropriate VTE prophylaxis.

Trends, Demographics, and Outcomes for Glucagon-Like Peptide-1 Receptor Agonist Use in Total Knee Arthroplasty: An 11-Year Perspective

BACKGROUND

Obesity and diabetes mellitus (DM) pose challenges for patients undergoing total knee arthroplasty (TKA). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as agents for weight and DM management, but they affect multiple organ systems. Outcomes, trends, and demographics for perioperative GLP-1RA use in patients with TKA are not well understood.

METHODS

A retrospective review of 13,751 primary, elective TKAs with at least 90 days of follow-up at an urban academic health system between 2012 and 2023 identified 865 patients who had perioperative GLP-1RA use. A 10:1 propensity score match based on sex, age, smoking status, American Society of Anesthesiologists classification, and body mass index created a control cohort of 8,650 TKAs with no GLP-1RA use.

RESULTS

The use of GLP-1RAs varied significantly by race, Medicaid insurance, Charlson Comorbidity Index, and presence of DM. Black and Latino patients and those covered by Medicaid were significantly less likely to receive GLP-1RAs. The GLP-1RA group had significantly shorter length of stay (2.1 versus 2.5 days, P < 0.001) and a higher rate of home discharge (91.7 versus 84.2%, P < 0.001). The GLP-1RA users had significantly higher rates of 90-day emergency department visits (5.9 versus 4.0%, P = 0.008), but no differences in 90-day readmissions (4.3 versus 3.6%, P = 0.168) or 2-year revision (2.3 versus 2.6%, P = 0.362) compared to matched controls. The GLP-1RA patients had significantly lower all-cause revision rates at the last follow-up (2.7 versus 3.9%, P = 0.034), but there was no significant difference in Kaplan-Meier implant survival (P = 0.311). Before TKA, GLP-1RA patients had an average decrease in body mass index of 0.4, compared to an average increase of 1.2 for matched controls.

CONCLUSIONS

Our results demonstrate that the use of GLP-1RAs is significantly lower for minority patients and those covered by Medicaid. Patients using GLP-1RAs have noninferior clinical outcomes with the potential for weight loss leading up to TKA.

LEVEL OF EVIDENCE

III.

Validation of a Novel Landmark-guided Intra-articular Postero-medial Surgeon-administered Injection Technique

Background

This study aimed to define an intra-articular surgeon-administered technique that may be comparable to ultrasound (US)-guided adductor canal block (ACB).

Methods

Five cadaver lower limbs were examined. An anesthesiologist administered a US-guided ACB using 20 mL of dilute indocyanine dye. An orthopedic surgeon performed a medial parapatellar arthrotomy and introduced an 18-gauge needle 1-2 cm proximal to the palpated adductor tubercle angled posteromedially. Needle position and dye spread were fluoroscopically documented.

Results

This technique consistently reached the infrapatellar branch of the saphenous nerve, nerve to the vastus medialis muscle, and posterior capsule, with minimal proximal dye spread.

Conclusions

This technique may be an efficient complement to ACB or surgeon infiltration or an alternative to US-guided ACB when it is not available.

Outpatient Total Knee Arthroplasty Has Become More Frequent Since the Onset of the COVID-19 Pandemic Without an Increase in Early Post-Operative Complications

BACKGROUND

Outpatient total knee arthroplasty (TKA) has quickly grown in popularity, largely driven by policy shifts and the recent coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to compare 30-day complications between outpatient TKA (oTKA) versus inpatient TKA (iTKA) before and after the COVID-19 pandemic to elucidate the effect of the pandemic on utilization and short-term outcomes.

METHODS

Patients who underwent primary TKA between 2008 and 2021 were identified through Current Procedural Terminology codes in a national database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared, and risk factors for adverse events were identified.

RESULTS

A total of 533,503 patients were identified, with 31,905 (6.0%) undergoing oTKA and 501,598 (94.0%) undergoing iTKA. Despite a rise in the frequency of oTKA over time, the rate of any adverse event (AAE) in the oTKA cohort remained significantly lower than that of iTKA (P < 0.001) from 2008 to 2021. This difference was maintained when comparing oTKA to iTKA AAE rates in the pre-COVID (2008 to 2019) and post-COVID (2020 to 2021) periods (P = 0.001 and 0.004, respectively). Postoperative transfusions were less frequent in oTKA cases for all years (P < 0.001) and were less frequent in postpandemic oTKA cases compared to prepandemic oTKA (P = 0.027). When controlling for all other factors, the outpatient operative setting emerged as a risk-reducing factor for AAE in both pre-COVID and post-COVID cohorts. In contrast, age, body mass index, and a history of chronic obstructive pulmonary disease increased the risk of experiencing an adverse event.

CONCLUSIONS

Despite a rapid increase in the utilization of oTKA after the onset of the COVID-19 pandemic, 30-day adverse events did not increase and remained lower than that of iTKAs overall. Our findings indicate that oTKA is associated with lower short-term (30-day) complications.

Cost Difference in Performing Total Knee Arthroplasty at Ambulatory Surgical Centers Compared With Hospital-Based Outpatient Departments: Observational Study

BACKGROUND

As total knee arthroplasty (TKA) further transitions toward an outpatient procedure, it becomes important to identify the resource utilization after TKAs at different outpatient facilities. The objective of this study was to determine the 90-day cost of patients who underwent TKAs at an ambulatory surgical center (ASC) or a hospital outpatient department (HOPD).

METHODS

An observational cohort study was conducted using the Marketscan database with patients who had a TKA at an ASC or HOPD between January 1st, 2019, and October 2nd, 2021. The primary outcome was cost in a 90-day period (including the day of surgery), with inpatient admissions and ED visits as secondary outcomes. Multivariable regression analyses were conducted, adjusting for patient characteristics.

RESULTS

The study population consisted of 47,261 patients with 7,874 ASC patients and 39,387 HOPD patients. 90-day costs for ASC patients were lower compared with HOPD patients ($35,634 ± 19,030 vs. $38,096 ± 24,389, P < 0.001). 90-day inpatient admission rates were lower for ASC than HOPD patients (2.5% vs. 4.8%, P < 0.001). 90-day ED visits for ASC patients were lesser compared with HOPD patients (8.9% vs. 12.7%, P < 0.001).

CONCLUSION

Patients with TKAs at an ASC had an overall lower cost, inpatient admissions, and ED visits over a 90-day period compared with HOPD patients. Future consideration for which outpatient facilities patients have their TKA at is necessary as TKAs shift toward bundle payments and outpatient procedures.

Short-Term (90 Days) Clinical Outcomes Following the Day of Surgery Conversion of Inpatient to Same-Day Hip and Knee Arthroplasty

BACKGROUND

The incidence of total joint arthroplasty is increasing, with added emphasis on shifting care toward outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion.

METHODS

We identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a 2-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including reoperation, readmission, and emergency room visits within a 90-day postoperative period.

RESULTS

We identified a total of 80 patients who converted from inpatient to outpatient surgery over a 2-year interval. Over the first 90 days postoperatively 4 (5%) patients were readmitted: 2 (2.5%) for medical complications and 2 (2.5%) for reoperation. There were 2 (2.5%) reoperations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were 5 (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of 5 (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission.

CONCLUSIONS

Hospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future

ABSTRACT

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices

BACKGROUND

Despite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA.

METHODS

This nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

RESULTS

Oral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted.

CONCLUSIONS

Perioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Outpatient Total Hip Arthroplasty Volume up Nearly 8-Fold After Regulatory Changes With Expanding Demographics and Unchanging Outcomes: A 10-Year Analysis

BACKGROUND

With the removal of total hip arthroplasty (THA) from the inpatient-only (IPO) lists, the orthopedic landscape across the United States has changed rapidly. Thus, this study aimed to: 1) characterize the change in THA volume for outpatient and inpatient surgeries; 2) elucidate demographical differences before and after removal from the IPO list; and 3) analyze 30-day complications, readmissions, and reoperations.

METHODS

The National Surgical Quality Improvement Program database was queried for primary THAs between January 2010 and December 2021. The primary outcome was the annual volume of outpatient and inpatient THAs. Secondary outcomes involved 30-day complications, readmissions, and reoperations. The variables between cohorts were analyzed using goodness-of-fit Chi-square tests with summary statistics.

RESULTS

Of the 332,423 THAs between 2010 and 2021, 88% were inpatient THAs (n = 292,974) and 12% were outpatient THAs (n = 39,449). From 2019 to 2021, the volume of inpatient THA decreased by 55% (42,779 to 19,075), while outpatient THA increased by 751% (2,518 to 21,424). Patients who had a THA after 2019 were older (P < .001), more commonly women (P < .001), white (P < .001), and more likely American Society of Anesthesiologists Class III (P < .001). The outpatient cohort had fewer 30-day complications, readmissions, and reoperations. The length of stay for both cohorts decreased until 2019, before increasing in 2020 and 2021 for inpatient THAs, while home discharge and operative time increased for both.

CONCLUSIONS

The volume of outpatient THA increased almost eightfold after its removal from the IPO lists in 2020. Despite expanding eligibility with older patients and more comorbidities, 30-day complications, readmissions, and reoperations remain low. These findings support the safe transition to outpatient THA with appropriate patient selection and optimization.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California

BACKGROUND

Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic.

METHODS

Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05.

RESULTS

In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA.

CONCLUSIONS

This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly.

LEVEL OF EVIDENCE

Therapeutic Level IV, Retrospective Cohort Study.

Can an Enhanced Recovery Protocol Result in a Safe and Effective Outpatient Simultaneous Bilateral Total Knee Arthroplasty?

BACKGROUND

Outpatient total knee arthroplasty (OP TKA) is found to benefit patients as well as the health care system. Studies on OP TKA have been limited to unilateral total knee arthroplasty (TKA). This study aimed to determine if enhanced recovery after surgery (ERAS) protocols can result in performing simultaneous bilateral TKA (SBTKA) safely and effectively in the OP setting.

METHODS

This retrospective study compared patients who underwent SBTKA in an OP setting (OP group, n = 100) using an ERAS protocol from April 1, 2021, to June 30, 2022, and a propensity-matched historical group (inpatient group, n = 100) operated in an inpatient setting via conventional protocol from July 1, 2019, to June 30, 2020. The complication rate, readmission rate, visual analog score (VAS), range of motion (ROM), and Knee Society Score (KSS) were compared between the groups in the early postoperative and follow-up periods up to 1 year.

RESULTS

We found a comparable complication rate (4 versus 7%, P = .4) and readmission rate (2 versus 3%, P = .7). The VAS score was significantly lower in the OP group on day 1, day 2, day 7, and day 14 postsurgery (P < .001). The KSS and ROM were significantly better in the OP group after 14 days (P < .001). The VAS, KSS, and ROM were comparable between the groups at 1 month and later follow-up periods (P > .05).

CONCLUSIONS

An ERAS protocol in SBTKA patients resulted in safe same-day discharge with better early functional outcomes compared with conventional practices. The results from similar future studies can alleviate surgeon and patient concerns about OP TKA.

Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System

BACKGROUND

Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years.

METHODS

Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons.

RESULTS

Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair.

CONCLUSION

The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.

Same-Day Total Joint Arthroplasty in the United States From 2016 to 2020: The Impact of the Medicare Inpatient Only List and the COVID-19 Pandemic

BACKGROUND

Same-day total hip arthroplasty (THA) and total knee arthroplasty (TKA) continue to gain popularity in the United States. The present study sought to quantify recent same-day outpatient trends taking into consideration the COVID-19 pandemic as well as the removal of these procedures from the Medicare inpatient only (IPO) list.

METHODS

Patients undergoing primary elective TKA and THA were identified using the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample from January 1, 2016, to December 31, 2020. The same-day cohort included Nationwide Ambulatory Surgery Sample and National Inpatient Sample patients with a length of stay = 0 days. The inpatient cohort included patients with length of stay ≥1 day. National estimates were extrapolated using weight functions.

RESULTS

From January 2016 to December 2020, the proportion of same-day TKA increased from 1.2 (719) to 62.4% (31,293) and the proportion of same-day THA increased from 2.0 (599) to 54.5% (18,252). Following removal from the Medicare IPO list, same-day TKAs increased from 3.2% (1,895) in December 2017 to 13.8% (9,269) in January 2018, and same-day THAs increased from 10.7% (4,295) in December 2019 to 22.5% (8,708) in January 2020. Between February and March 2020, same-day TKAs increased from 42.4 (26,148) to 44.4% (16,972) and same-day THAs increased from 28.5 (10,729) to 30.2% (7,409).

CONCLUSIONS

The proportion of same-day TKA and THA dramatically increased following removal from the Medicare IPO list and in response to the COVID-19 pandemic. By December 2020, same-day TKA and THA accounted for >50% of all cases performed in the United States.

Considering Mobility Status and Home Environment in Readmission Risk After Total Knee Arthroplasty

BACKGROUND

Discharge disposition following total knee arthroplasty (TKA) offers varying levels of post-acute care monitoring depending on the medical status of the patient and his or her ability to function independently. Discharge disposition following TKA is associated with 30-day and 90-day hospital readmission, but prior studies have not consistently considered confounding due to mobility status after TKA, available caregiver support, and measures of home area deprivation. The purpose of this study was to examine 30-day and 90-day readmission risk for patients discharged to a skilled nursing facility (SNF) following TKA after controlling specifically for these factors, among other covariates.

METHODS

This was a retrospective cohort study of patients undergoing TKA at any of 11 hospitals in a single, large, academic health-care system between January 2, 2017, and August 31, 2022, who were discharged to an SNF or home health care (HHC). The adjusted relative risk of readmission within 30 and 90 days of discharge to an SNF compared with HHC was estimated using modified Poisson regression models.

RESULTS

There were 15,212 patients discharged to HHC and 1,721 patients discharged to SNFs. Readmission within 30 days was 7.1% among patients discharged to SNFs and 2.4% among patients discharged to HHC; readmission within 90 days was 12.1% for the SNF group and 4.8% for the HHC group. The adjusted relative risk after discharge to an SNF was 1.07 (95% confidence interval [CI], 0.79 to 1.46; p = 0.65) for 30-day readmission and 1.45 (95% CI, 1.16 to 1.82; p < 0.01) for 90-day readmission.

CONCLUSIONS

Discharge to an SNF compared with HHC was independently associated with 90-day readmission, but not with 30-day readmission, after controlling for mobility status after TKA, available caregiver support, and home Area Deprivation Index, among other covariates.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Multiple sclerosis is associated with adverse outcomes following hip and knee arthroplasty: A systematic review and meta-analysis of observational studies

BACKGROUND

The association of multiple sclerosis (MS) with joint diseases has been established. However, the impact of MS on postoperative outcomes following total joint arthroplasty (TJA) remains controversial. Therefore, a systematic review of the literature is warranted to ascertain the relationship between MS and adverse outcomes post-TJA.

METHODS

A systematic literature search of PubMed, Embase, Scopus, and the Cochrane Library from inception to 1 March 2023 was conducted to identify observational studies comparing post-TJA outcomes in MS and non-MS patients. Two investigators independently screened titles, abstracts, and full-text articles for eligibility. A random-effects model was used to calculate odds ratios (OR), mean differences (MD), and corresponding 95% confidence intervals (CI).

RESULTS

Seven retrospective cohort studies published between 2018 and 2022 met the inclusion criteria. Patients with MS had a higher risk of medical, surgical, and overall complications than patients without MS. Similarly, the MS group was more likely to experience an extended hospital stay, non-home discharge, and revision surgery compared to the control group. Joint infection and implant instability were also more common in patients with MS.

CONCLUSION

Although TJA may benefit MS patients, current evidence suggests that their postoperative outcomes may be inferior to those of non-MS patients. Thus, orthopaedic surgeons should inform MS patients of potential risks and perform preoperative optimization individually when considering elective arthroplasty.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications

Introduction

An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database.

Methods

Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities.

Results

Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA.

Conclusion

Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.