Trends in Outpatient Total Knee Arthroplasty (TKA) from 2012 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.

A Proposed Patient Selection Algorithm for Total Joint Arthroplasty Same-Day Discharge From an Ambulatory Surgery Center

BACKGROUND

Identifying appropriate patients for same-day discharge (SDD) total joint arthroplasty (TJA) is critical for maintaining optimal patient safety and outcomes. This study investigated patient outcomes after SDD TJA at a single ambulatory surgery center (ASC) and proposes a TJA patient-selection algorithm based on findings and existing literature.

METHODS

A retrospective chart review of 660 patients was performed between July 2019 and October 2021 for all patients who underwent primary TJA in a single ASC. Successful SDD, length of surgery, estimated blood loss (EBL), complications, and readmission events were recorded for each patient. There were 20 total complications in 331 primary total knee arthroplasties (TKAs) (6.0%) and 15 total complications in 329 primary total hip arthroplasties (THAs) (4.6%).

RESULTS

There was one direct admission to the hospital in TKA patients and four direct admissions in THA patients, making the successful SDD rate 99.7% in TKAs, 98.8% in THAs, and 99.2% overall. In the TKA cohort, body mass index was associated with total complications (r = -0.15, P = 0.006); comorbidities with wound complications (P = 0.006); and EBL was with readmissions (r = 0.30, P < 0.001), revision surgery (r = 0.12, P = 0.04), and total complications (r = 0.16, P = 0.03). In the THA cohort, body mass index was weakly associated with wound complications (r = -0.12, P = 0.02), EBL was with emergency department visits (r = 0.18, P = 0.002) and total complications (r = 0.14, P = 0.01). However, there was no direct association between any of the analyzed characteristics and direct admission.

CONCLUSIONS

In our ASC cohort, patients had low rates of perioperative complications and hospital admissions, supporting the safety of SDD TJA using our proposed evidence-based algorithm to guide patient selection for SDD.

Weekend versus Weekday Procedures for Total Knee Arthroplasty

This study compares the outcomes of elective total knee arthroplasty (TKA) on a weekday versus the weekend. Patients undergoing elective TKA from 2016 to 2020 were identified using the Healthcare Cost and Utilization Project database. Demographics and hospital-related outcomes including length of stay (LOS), total charges, pain, wound disruption, implant infection, and mortality, were collected. Perioperative outcomes were assessed from each patient's concurrent diagnoses. Multivariable analysis was performed. A total of 586,285 patients who underwent elective TKA were identified, of which 2,199 (0.37%) were performed on the weekend. Patients undergoing weekend TKA were slightly older (68.055 ± 9.882 vs. 66.699 ± 9.454, p < 0.001), and had a statistically significant predilection toward Asians, Hispanics, and Blacks (p < 0.001). No significant difference was present in gender, obesity, or preoperative conditions. Weekend TKA patients had increased odds of prolonged LOS (odds ratio [OR]: 1.154 for LOS ≥3 days, p = 0.002) and higher total charges (OR: 1.328, p < 0.001), along with higher odds of uncontrolled pain (OR: 1.257, p = 0.001) and implant infection (OR: 1.418, p = 0.004). No significant differences in wound disruption or mortality were found. Our findings indicate an association between weekend TKA and increased pain, implant infection, LOS, and cost, validating the presence of a weekend effect on TKA. Future research is needed to clarify the underlying causes of this association and feasible ways to mitigate its impact.

Hospital and Patient Factors Associated With Length of Hospitalization in Patients Who Have Osteoarthritis Undergoing Primary Total Knee Arthroplasty: An Analysis of National Data

BACKGROUND

By 2040, an estimated 3.5 million primary total knee arthroplasties (TKAs) are expected to be performed annually in the United States. Osteoarthritis (OA) is the most common indication for primary TKA. We examined the association of hospital, regional, and patient-level factors with extended lengths of hospital stay (eLOS).

METHODS

We studied patients who have OA who underwent primary TKA from 2016 to 2019 using a national inpatient database. We used the International Classification of Diseases codes to identify diagnoses and procedures. There were 2,592,469 patients who had OA who underwent primary TKA from 2016 to 2019. We used univariate and multivariable-adjusted logistic regression analyses to assess whether patient, payer, hospital, and geographic factors were associated with an eLOS. Predictive probabilities from multivariable analyses were used to estimate the area under the curve.

RESULTS

Patient race and ethnicity, Medicaid or Medicare payer status, income, age/sex, and nearly all regional and hospital characteristics were independently associated with eLOS (>3 days; receiver-operating characteristic C-statistic = 0.74). Sensitivity analyses that used the most recent years of data from 2020 to 2021 (COVID-19 pandemic years) or adjusted for individual organ system complications reproduced the main results without much attenuation.

CONCLUSIONS

Age, sex, race, ethnicity, hospital location and teaching status, elective procedure designation, perioperative complications, and insurance payer status significantly influenced the LOS for primary TKA hospitalizations in the United States. Recognized disparities were linked to longer hospital stays after primary TKA in patients who had OA. Implementing policies and interventions that target these factors could help shorten hospital stays for high-risk patients after primary TKA.

Chronic Anticoagulation in Patients Who Have Atrial Fibrillation Undergoing Outpatient Total Knee Arthroplasty: A Retrospective Matched Cohort Study

BACKGROUND

Patients who have atrial fibrillation frequently require long-term anticoagulation with warfarin or a direct-acting oral anticoagulant (DOAC), such as apixaban or rivaroxaban, to avoid vascular complications. However, the impact of anticoagulant use on postoperative complications following total knee arthroplasty (TKA) in an outpatient setting has not been thoroughly elucidated. The purpose of this study was to examine the impact of anticoagulant use on early postoperative complications among atrial fibrillation patients undergoing outpatient TKA.

METHODS

An insurance claims database was queried to identify all patients who underwent outpatient TKA between January 2010 and April 2022. There were two cohorts of patients, with associated 1:1 matched controls, who had atrial fibrillation and filled a prescription of either warfarin (N = 4,396) or DOAC (N = 5,383) for at least 30 days. The mean age was 70 years (range, 51 to 84), and 47.9% were women in the warfarin cohort, while the mean age was 70 years and 49.2% were women in the DOAC cohort. Postoperative 30-day medical and 90-day surgical complications were subsequently compared.

RESULTS

Patients on warfarin had a higher incidence of pulmonary embolism (1.1 versus 0.2%, P < 0.001) and a lower incidence of TKA revision (0.1 versus 0.4%, P = 0.003) than matched controls. Similarly, patients on DOACs exhibited a higher incidence of pneumonia (1.4 versus 0.6%, P < 0.001) and myocardial infarction (3.2 versus 1.5%, P < 0.001) and a lower incidence of wound dehiscence (0.1 versus 0.5%, P < 0.001), joint infection (0.4 versus 0.9%, P = 0.002), and TKA revision (0.1 versus 0.4%, P = 0.002) than matched controls.

CONCLUSIONS

Atrial fibrillation patients on long-term anticoagulants undergoing outpatient TKA experience higher rates of medical complications and lower rates of surgical complications than matched controls. Thus, patients on long-term anticoagulants may be considered for outpatient TKA but should be counseled appropriately on associated medical risks.

Percutaneous auricular neuromodulation for postoperative analgesia

INTRODUCTION

Postoperative pain is often severe, with many patients still experiencing significant pain upon discharge. While opioids are effective for pain relief, they have numerous side effects and carry a high risk for misuse and dependence. Auricular electric stimulation, a form of neuromodulation, offers a promising alternative by electrically stimulating nerves of the auricle to modulate central pain pathways, potentially reducing postoperative pain and opioid requirements.

AREAS COVERED

This review, based on a search of the MEDLINE/PubMed, Scopus, and Cochrane review online sources from 1980 to 2024, discusses the use of auricular electric stimulation as a form of neuromodulation for management of postoperative pain focusing on the available evidence and future avenues for research.

EXPERT OPINION

Percutaneous auricular nerve stimulation offers a promising neuromodulation technique for managing postoperative pain. By modulating central pain processing through peripheral stimulation, this approach may reduce pain during recovery. Small pilot studies have suggested that auricular stimulation may lower pain intensity and reduce opioid consumption after surgery; however, further research is needed regarding both potential benefits and risks. As a minimally invasive technique, percutaneous auricular stimulation may provide a valuable adjunct to multimodal analgesia, especially in patients at risk of opioid-related complications.

Cost-Volume Analysis of Primary Total Knee and Hip Arthroplasty in the United States

BACKGROUND

Utilization of total knee arthroplasty (TKA) and total hip arthroplasty (THA) arthroplasty is increasing along with associated hospitalization costs. A contemporary analysis of the impact of hospital case volume on the costs of TKA and THA is lacking.

METHODS

Adults undergoing primary elective TKA or THA who had a diagnosis of osteoarthritis were identified from an inpatient all-payer database from 2012 to 2019. Operative volume was ascertained with restrictive cubic spline analysis. The volume corresponding to the inflection point of the spline was used to stratify hospitals as high volume (HVH) or low volume (LVH). Multivariable regression models were developed to examine the association of volume with hospitalization costs, adverse events, lengths of stay, and nonhome discharges.

RESULTS

Of the 7,781,233 patients undergoing TKA or THA over the study period, 73.1% of primary TKA and 77.1% of primary THA were managed at HVH. On adjustment for patient and hospital covariates, treatment at high-volume TKA or THA hospitals was associated with a cost decrement of $2,200 (95% confidence interval, 2,900 to 2,400, P < 0.001), and $1,900 (95% confidence interval, 2,100 to 1,600), respectively. Notably, the disparity in hospitalization costs between HVH and LVH markedly increased during the study period (P < 0.001).

CONCLUSIONS

Greater TKA and THA volume was associated with reduced hospitalization costs. These findings suggest that regionalization of care to experienced hospitals may improve the value of orthopaedic surgical care.

Ultrasound Guided Genicular Nerve Blocks for Pain Management Following Total Knee Replacement: A Narrative Review

PURPOSE OF REVIEW

Total knee replacement (TKR) is a common procedure to alleviate pain in patients with severe osteoarthritis of the knee after failed conservative treatment. While generally safe, postoperative pain is a significant issue many patients experience following surgery.

RECENT FINDINGS

To control postoperative pain, numerous treatments may be administered which may be given preoperatively, intraoperatively, or postoperatively. These treatments include medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids. Additionally, peripheral nerve blocks (PNB) may be performed prior to total knee replacement to limit pain after the surgery. A specific type of PNB done prior to total knee replacement is the genicular nerve block (GNB) which targets five genicular nerves that innervate different parts of the knee joint. This type of block is designed to prevent pain impulses from being sent to the central nervous system from the knee without affecting movement of the lower extremity by sparing efferent nerves innervating muscles. PubMed was used to identify the studies found in this review that are less than 5 years old using the search term "genicular nerve block clinical studies." Most studies compared GNB alone compared to other blocks, however some used GNB in combination with other blocks, most at a maximum of 48 h postoperative. GNB is typically performed by anesthesiologists under ultrasound guidance to ensure accurate placement of the block. Clinical studies have shown that GNB is effective in controlling pain following TKR leading to lower pain scores following surgery as well as a reduced level of opioid consumption. Additionally, GNB has shown reduced motor weakness following TKR compared to other types of PNBs allowing earlier mobilization of patients. However, more studies are needed to further investigate the efficacy of GNB compared to other PNBs to treat postoperative pain following TKR.

Comparative efficacy and safety of bicompartmental versus total knee arthroplasty: a systematic review and update meta-analysis

BACKGROUND

This study was aimed at comparing the efficacy and safety of bicompartmental knee arthroplasty (BKA) and total knee arthroplasty (TKA) in treating bicompartmental knee osteoarthritis through a systematic evaluation and meta-analysis.

METHODS

A comprehensive systematic literature search of the Pub Med, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov databases was performed to identify the relevant scientific literature published until 1st March 2024. The eligible studies were evaluated for quality assessment and data extraction, and meta-analysis was performed using Review Manager 4.1 software.

RESULTS

A total of 1378 studies were identified. Based on strict inclusion criteria, 12 studies were finally included in this meta-analysis. The results of the analysis revealed that BKA yielded better postoperative outcomes than TKA, in terms of Knee Society Score (KSS) Knee Score, Function Score, and range of knee flexion (P = 0.02; P < 0.0001; P = 0.0005, respectively). Intraoperative bleeding in the BKA group was significantly lower than that in the TKA group (P = 0.02), although postoperative complications (P < 0.05) were higher and operative time (P = 0.04) was longer in the BKA group. However, the two groups did not show any significant difference in terms of Oxford knee score and WOMAC pain score (P = 0.53 and P = 0.96, respectively).

DISCUSSION

Our present results indicate that while BKA affords better improvement in knee function and quality of life in bicompartmental knee osteoarthritis than TKA, it also increases complications and operative time. Therefore, further studies are warranted to confirm these results and assess long-term outcomes and cost-effectiveness.

OTHER

Systematic review registration PROSPERO CRD420-24551418.

Short-Term Outcomes of Noncemented Total Knee Arthroplasty in Patients With Morbid Obesity

INTRODUCTION

Noncemented primary total knee arthroplasty (TKA) compromises over 14% of all primary TKA procedures reported in the American Joint Replacement Registry. While studies have indicated similar outcomes for cemented and noncemented TKA in obese individuals, the efficacy and safety of noncemented TKA in morbidly obese patients (body mass index [BMI] ≥ 40 kg/m2) remain unexplored. This study compares short-term postoperative outcomes and complications between noncemented and cemented TKA in morbidly obese patients.

METHODS

A retrospective review of 605 cases of patients with a BMI of at least 40 kg/m2 (22.5% of 2,691 total cases at a single tertiary center) who underwent TKA was conducted. All patients had a minimum follow-up of 1 year. Data collected included age, BMI, sex, race, ethnicity, American Society of Anesthesiologists status, and the Charlson Comorbidity Index. Postoperative complications were tracked, including 90-day readmission, 1-year mortality, 1-year revision surgery, wound complications, fractures, and infections. Categorical variables were analyzed with chi-square tests and continuous variables with t-tests.

RESULTS

Of the included patients with a BMI ≥ 40 kg/m2, 40 (6.6%) received noncemented TKA. The noncemented TKA group had a lower mean BMI (43.3 ± 3.1 vs. 45.0 ± 4.4; P = 0.012) and a higher proportion of male patients compared with the cemented group (n = 17 [42.5%] vs. n = 143 [25.3%]; P = 0.028). Surgical time was shorter for noncemented TKA (97 ± 27 minutes) than for cemented TKA (118.0 ± 39.4 minutes; P = 0.001). No significant differences were found in length of stay and postoperative complications, including 90-day readmission, 1-year mortality, revision surgery rates, wound complications, fractures, and infections.

CONCLUSION

The findings of the study suggest that noncemented TKA may be a feasible, safe alternative and not inferior to the standard cemented TKA in patients with morbid obesity with the benefit of decreasing surgical time.

Effect of Phase Angle on Change in Quadriceps Muscle Strength 1 Year After Total Knee Arthroplasty: The Screening for People Suffering Sarcopenia in Orthopedic Cohort of Kobe Study

BACKGROUND

Phase angle (PhA) has been reported to be associated with quadriceps strength in patients who have knee osteoarthritis and were scheduled for total knee arthroplasty (TKA). The PhA can also be expected to predict the time course of quadriceps muscle strength loss and recovery. We aimed to investigate the relationship between the preoperative PhA and the time course of quadriceps muscle strength change in patients undergoing TKA.

METHODS

A prospective cohort study was conducted on patients scheduled for primary unilateral TKA. A total of 855 patents were included in the analysis. The PhA and quadriceps muscle strength of the operated knee were measured preoperatively and at 3, 6, and 12 months postoperatively. To analyze the effect of the preoperative PhA on the change in postoperative quadriceps muscle strength, a linear mixed model with the quadriceps muscle strength as a dependent variable with the preoperative PhA, evaluation period (dummy variable), and their product terms as independent variables was conducted after adjusting for preoperative covariates.

RESULTS

A statistically significant negative effect was present for a higher PhA, resulting in a greater decrease in quadriceps muscle strength between preoperative and 3 months postoperative (P = 0.012). In contrast, the effect was not statistically significant between 3 and 6 months postoperatively (P = 0.17). However, a statistically significant positive effect for a higher PhA resulting in a greater increase in quadriceps muscle strength was present between 6 and 12 months postoperatively (P = 0.027).

CONCLUSIONS

Preoperative PhA is a useful predictor of the quadriceps muscle strength change after TKA. These findings suggest that evaluating the preoperative PhA could aid in the development of targeted rehabilitation programs aimed at optimizing quadriceps muscle function in patients undergoing TKA.

Safety and efficacy of outpatient versus inpatient adult brachial plexus surgery

Purpose

Outpatient orthopedic surgery is becoming more common as a method of providing safe and cost-effective medical care. The purpose of this study was to compare outcomes between adult patients undergoing outpatient versus inpatient brachial plexus surgery.

Methods

A single institution database was queried for patients with brachial plexus injuries undergoing brachial plexus exploration with or without concomitant reconstructive procedures from 2010 to 2022. Outcome measures included 90-day major and minor complications, as well as longer term pain scores and reoperation rates. Multivariate analysis was performed to compare outcomes between the cohorts.

Results

In a group of 51 adult patients, 36 (70.6 %) were admitted for at least one night following surgery and 15 (29.4 %) underwent outpatient surgery. The cohorts were similar with respect to demographics. When compared to brachial plexus procedures performed between 2010 and 2016, those performed between 2017 and 2022 were 67 % more likely to be outpatient (OR 0.33; p = 0.11). The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6), all of which occurred in the inpatient cohort. There was no significant difference in minor complication rate. 90-day reoperation rate due to complications was 2.8 % in the inpatient cohort and 0.0 % in the outpatient cohort.

Conclusion

No prior study has assessed the safety of brachial plexus exploration and reconstruction in an outpatient setting. This study demonstrates that outpatient brachial plexus surgery is a safe option for properly selected patients. Procedures were more often performed outpatient in recent years, reflecting a continuing evolution of our practice.

Episode-of-care costs of total knee arthroplasty: Outpatient versus inpatient postoperative care protocol

BACKGROUND

Total knee arthroplasty (TKA) is the most commonly performed joint replacement procedure in North America. Few studies have successfully evaluated the episode-of-care cost (EOCC) of common elective orthopedic procedures using an activity-based costing (ABC) framework. The objective of this study is to compare the EOCC of same-day discharge versus inpatient TKA using an activity-based costing methodology.

METHODS

An observational case-control study was conducted comparing the EOCC of 25 consecutive patients who underwent same-day discharge (SDD) TKA and 25 consecutive patients who underwent same-day admission (SDA) TKA at an academic center. The EOCC was generated using an ABC framework.

RESULTS

The median total EOCC for outpatient TKA was $7,243.26 CAD (IQR=614.12), while the median EOCC in the inpatient group was $8,303.94 CAD (IQR=1,157.77). The costs incurred secondary to the hospital admission were the main driver of the increased cost for inpatients. The mean length of stay for admitted patients was 2.45 days (SD=1,52). Patients in the outpatient group were younger (p < 0.01) and had a lower mean Charlson Comorbidity Index group (p = 0.01). There was no significant difference in gender, BMI, ASA scores, and complication rates between the two groups.

CONCLUSION

Through the application of an ABC framework, this value-based healthcare study demonstrates that outpatient procedures are a cost-effective approach to knee arthroplasty. Our findings demonstrate that the total cost of outpatient TKA was on average 15% ($1,060 CAD) lower than the cost of TKA with the standard inpatient postoperative care protocol.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis

OBJECTIVES

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity.

BACKGROUND

An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR.

METHODS

Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity.

RESULTS

Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR.

CONCLUSIONS

Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

BACKGROUND

Recent literature suggests a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, the impact of increased comorbidities on the cost-effectiveness of TKA is underexplored. This study aimed to compare the financial implications and perioperative outcomes of patients with and without a high comorbidity burden (HCB).

METHODS

We retrospectively reviewed 10,647 patients who underwent elective, unilateral TKA between 2012 and 2021 at a single academic health center with available financial data. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups. A 1:1 propensity match was performed based on baseline characteristics, resulting in 1,536 matched patients (768 per group). Revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. Ninety-day readmissions and revisions were also analyzed.

RESULTS

The HCB patients had significantly higher total (P < 0.001) and direct (P < 0.001) costs, while hospital revenue did not differ between cohorts (P = 0.638). This disparity resulted in a significantly decreased CM for the HCB group (P = 0.009). Additionally, HCB patients had a longer length of stay (P < 0.001) and a higher rate of 90-day readmissions (P = 0.005).

CONCLUSIONS

Increased inpatient costs for HCB patients undergoing TKA were not offset by proportional revenue, leading to a decreased CM. Furthermore, higher 90-day readmissions exacerbate the financial burden. These findings highlight potential challenges for hospitals in covering indirect expenses, which could jeopardize accessibility to care for HCB patients. Reimbursement models should be revised to better account for the increased financial burden associated with managing HCB patients.

LEVEL OF EVIDENCE

III.

Comparison of Patients Based on Their Self-Selected Discharge Pathway after Total Knee Arthroplasty at an Ambulatory Surgical Center

Outpatient total knee arthroplasty (TKA) is being performed more frequently in ambulatory surgical centers (ASCs) to decrease the cost of care. Discharge pathways include 23-hour observation (OBSERVATION) or same-day discharge home (HOME), which differ in postoperative medical supervision. Few studies allow patients to self-select their discharge pathway. This study compared patient variables between self-selected OBSERVATION or HOME discharge after TKA at an ASC. We hypothesized that age, sex, and distance lived from the ASC would differ between discharge pathways. Clinical and patient-reported outcomes were explored.A chart review identified 130 patients with TKA at an ASC between November 2017 and December 2019. Patients self-selected OBSERVATION or HOME during a preoperative physician visit. Patient variables obtained from the electronic medical record were age, sex, race/ethnicity, marital status, body mass index, diabetic status, American Society of Anesthesiologists (ASA) class, distance lived from the ASC, anesthesia type, procedure time, and time in the postanesthesia recovery unit. Clinical outcomes (knee range of motion, infection rate, and reoperation rate) and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS, JR]; Oxford Knee Score [OKS]) were collected at either 6 or 12 weeks postsurgery. Variables were compared between groups.Pathway selection was n = 70 OBSERVATION and n = 60 HOME, and all patients completed their self-selected discharge pathway. Age and proportion of females were significantly higher in OBSERVATION than in HOME (61.3 ± 3.5 vs. 58.5 ± 5.4 years, 85.7 vs. 65.0%, respectively; p < 0.05). Distance lived from the ASC tended to be greater in OBSERVATION than HOME (22.1 ± 24.6 vs. 15.3 ± 10.1 miles, p = 0.056). Across groups, clinical outcomes were favorable (i.e., >88% met the 6-week knee flexion milestone, 1.9% infection rate, and 3.1% manipulation under anesthesia), and the preoperative to 12-week postoperative change in KOOS, JR and OKS scores met the minimal clinically important difference.Older age, female sex, and farther distance lived from the ASC may influence patients to select OBSERVATION over HOME discharge following TKA at an ASC. No robust differences were found in early outcomes.

Successful 24-hour discharge for total knee arthroplasty: importance of timing of surgery and physiotherapy in enhanced recovery after surgery protocol

INTRODUCTION

The current literature is mixed on which patient factors, if any, predict the rate of successful discharge within 24 h of enhanced recovery after surgery (ERAS) total knee arthroplasty (TKA). This study aimed to investigate the influence of timing of surgery and physiotherapy on the rate of successful 24-h discharge.

METHODS

All 342 patients who underwent ERAS day surgery TKA from August 2020 to July 2021 were followed up prospectively. Patient characteristics and postoperative outcomes, such as number of physiotherapy sessions required before clearance for home, time taken after surgery to ambulate >10 m and length of stay (LOS), were recorded. Patients were grouped based on surgical end time (morning/afternoon/ evening) and time of physiotherapy review (morning/afternoon/evening/morning after). Patients successfully passed ERAS day surgery protocol if they were discharged within 24 h.

RESULTS

With regard to the timing of operation, the morning group had the shortest LOS (P = 0.001) and a higher ERAS day surgery pass rate than the afternoon group (P = 0.016). With regard to the timing of physiotherapy, the afternoon group took the shortest time to ambulate >10 m (P < 0.001), had the shortest LOS (P < 0.001) and had a higher ERAS day surgery pass rate as compared to the morning after the operation group (P = 0.005).

CONCLUSION

Patients who ended their operations in the morning and received physiotherapy review in the same afternoon were the most likely to be discharged within 24 h due to early ambulation and adequate time for spinal anaesthesia to wear off.

Forecasting the value of innovation in total knee arthroplasty care: A headroom approach

Purpose

Total knee arthroplasty (TKA) is the standard treatment of end-stage osteoarthritis. TKA is often used and, therefore, poses a healthcare and societal burden, which is likely to increase further. Headroom analyses evaluate a technology under development by making assumptions about its effectiveness. This article applies a headroom approach to forecast the potential value of innovations that improve TKA-related care in the Netherlands in terms of cost-effectiveness and surgeries avoided.

Methods

A state-transition model estimating lifetime direct health effects, healthcare- and societal costs and percentage of avoide d surgeries was developed. The model compared care as usual to five hypothetical interventions to calculate the headroom associated with (1) preventing the need for TKAs, (2) preventing the need for all TKA revisions, (3) postponing TKAs without quality-of-life loss, (4) preventing periprosthetic joint infections (PJIs) and (5) improving patient satisfaction.

Results

Preventing the need for all TKAs amounted to €43,076 of headroom. Preventing the need for TKA revisions amounted to €2276 (5.8% of surgeries avoided), postponing TKAs by 5 years amounted to €7634 (32.4% of surgeries avoided), preventing PJIs amounted to €1187 (1.4% of surgeries avoided) and improving patient satisfaction amounted to €16,622 (0% of surgeries avoided). The headroom of each hypothetical intervention was highest in younger populations (<50 years of age).

Conclusion

There is a headroom for improving TKA-related care. Innovations to avoid or postpone TKA (i.e., joint-preserving treatments) as well as those that improve patient satisfaction can be effective in maximizing the value for money and avoiding surgeries. Due to the decreasing average patient age, innovations to reduce revision rates and PJIs will become more valuable as these are most effective in younger patients. It is currently unclear how cost-effectiveness considerations should be traded off against the prevention of surgery to reduce the increasing burden on the healthcare system.

Level of Evidence

Level III economic evaluation/decision-analytic model.

Is It Getting More Expensive to Treat Patients Who Have a High Comorbidity Burden? Financial Trends in Total Knee Arthroplasty From 2013 to 2021

BACKGROUND

Utilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time.

METHODS

Of 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance.

RESULTS

From 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period.

CONCLUSIONS

The results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

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.

Addition of Surgeon-Administered Adductor Canal Infiltration to the Periarticular Infiltration in Total Knee Arthroplasty: Effect on Pain and Early Outcomes

BACKGROUND

Our aim was to study the additive effect of surgeon-administered adductor canal infiltration (SACI) over routine periarticular infiltration (PAI) on pain control [morphine consumption and pain score by the visual analog scale (VAS)] and early function [flexion and Timed Up and Go (TUG) test] post-total knee arthroplasty (TKA).

METHODS

We prospectively randomized 60 patients into 2 groups. Group I patients received the standard PAI, whereas in Group II, the patients received a SACI in addition to the PAI. The total volume of the injected drug and the postoperative pain management protocol were the same for all. The number of doses of patient-controlled analgesia (PCA) used for breakthrough pain was recorded as PCA consumption. For early function, flexion and the TUG test were used. The VAS score and PCA consumption were compared between the 2 groups by using analyses of variance with post hoc tests as indicated. The TUG test and flexion were compared using Student t tests. The level of significance was set at 0.05.

RESULTS

The PCA consumption in the first 6 hours was significantly higher in Group I (P = .04). The VAS at 6 hours was significantly lower in Group II (P = .042). The TUG test was comparable between the 2 groups preoperatively (P = .72) at 24 hours (P = .60) and 48 hours (P = .60) post-TKA. The flexion was comparable between the 2 groups preoperatively (P = .85) at 24 hours (P = .48) and 48 hours (P = .79) post-TKA.

CONCLUSIONS

Adding a SACI to PAI provides improved pain relief and reduces opioid consumption without affecting early function post-TKA. A SACI avoids the need for an anesthesiologist or specialized equipment with no added operating time and minimal added cost. We recommend routine use of SACI for all patients undergoing TKA.

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review

BACKGROUND

Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations.

QUESTIONS/PURPOSES

In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?

METHODS

On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed.

RESULTS

There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores.

CONCLUSION

Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.